Intake Form First Name(Required)Last Name(Required)Middle Name or InitialDate Of Birth(Required) Month Day Year ----Relationship Status(Required)Select one:MarriedSingleDivorcedPartneredSpouse or Partner's Name (if applicable)Please describe briefly what you are wanting help with:(Required)----Have you had previous counseling?(Required) Yes No If yes, please explain more details (when was it, how long did you go, what did you go for, how was the experience, etc).What does your spouse/partner do for work?Provide details on your current marriage/relationship? How long have you been together/married? How would you describe your relationship? etc.Provide details on any past marriages/relationships (how long did it last, when did it end, what was the relationship like, etc).List how many children you have and their ages. Also describe which relationship they are from (your current relationship or a past relationship) and the quality of your relationship with them.Any military history? Yes No If yes, what branch, what was your experience, when did you serve?What do you do for work?How long have you been there?How do you like your job?Describe any religious or spiritual beliefs you have.List any hobbies or interests you have.Any past trauma or abuse? If so, please provide any details that you are comfortable sharing.List any medications (if applicable). Also describe how long you have been on them and how effective you feel they have been.Describe any medical problems or health concerns.Who prescribes your medications?Describe any substance use history (past and present). Include the frequency and quantity of use.Describe your family of origin. Are your parents still married? What was their relationship like? List your siblings and their ages. Describe your relationship with your parents and siblings.Describe your social life? Do you have many friends? How often do you do things with them?Describe your educational background. (highest degree, what you studied, etc) Δ