Intake Form — TUNE UP YOUR RELATIONSHIP
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Welcome
How We Work
Appointments
About Us
SOCIAL JUSTICE RESOURCES
Contact
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TUNE UP YOUR RELATIONSHIP
Even One Session Can Make A Difference
Intake Form
Date
MM
DD
YYYY
Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Phone 1
(###)
###
####
Message O.K.
Text O.K.
Phone 2
(###)
###
####
Message O.K.
Text O.K.
Relationship Status
Length of Time
Children?
How did you hear about us?
Have you had previous counseling?
What was the best part of that experience?
Please describe the problem that brings you in and the effects it has on your life:
How much is this issue interfering with your relationship currently?
1 - not at all, 10 - extremely
1
2
3
4
5
6
7
8
9
10
Please describe yourself apart from this issue (what hobbies do you have; what brings you joy):
How is your physical health?
What medications are you currently taking?
Please indicate any areas of additional concern:
Trouble Sleeping
Diabetes
Heart Problems
Chronic Pain
Depression
High Blood Pressure
Anxiety
Mood Swings
Anger
Have you had any problems with alcohol or drugs currently or in the past?
Please Describe:
What else do you think we should know?
Thank you!
Thank you for taking the time to fill out this form.