Family Intake Form

Name
First Last
Date
MM slash DD slash YYYY
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Worksite
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Work)
Phone (Home)
Phone (Preferred contact number)
Email
Age
Date of Birth
MM slash DD slash YYYY
Living Status
No. of Years of Living Status
Occupation
No. of years with current employer
Highest Level of Education

Briefly describe your reason for seeking help
Who suggested you contact us?
When were you last examined by a physician?
Physician’s Address
Street Address Address Line 2 City Country
Physician’s Phone
List any major health problems for which you currently receive treatment
List any medication you are currently taking
Have you or any of your family members received psychiatric or psychological help or counselling of any kind before?
- Yes
- No
If yes, please explain
If family member, please eplain
How will you know if counselling has been successful?