Relationship Counselling Intake Form

EMPLOYMENT INFORMATION: Vocation/Postion/Student, F/T, P/T, On leave (start date/end date), not working.

PSYCHIATRIC AND MEDICAL HISTORY: Please list any psychiatric or “mental” problems you have been diagnosed with. Please list any medical or “physical” problems that you have been diagnosed with. Please list any medications you currently take, and what you take them for.

What is your current living situation? Are you living with the person/persons you are recieving counselling with?

Whose idea was it to seek counselling? Was there a prompting event that led someone to make this call? Why seek help now?

Have you received prior couple counselling? What length of time? And, if yes, for what problems?

Name the top three concerns that you have in your relationship (“1” being the most problematic):

STRESSFUL LIFE EVENTS: Please describe any significant or stressful life events that you have been experiencing (economic problems, difficulty accessing health care, legal issues or crime, cultural issues, family conflict or lack of support, social problems, educational or occupational difficulties, housing problems, grief or bereavement, other?):

Does anyone in the relationhip drink alcohol or take drugs to intoxication? If yes, who, how often and what drug/alcohol?

Has anyonein the relationship physically restrained, harmed, or injured another person? E.g., pushed, shoved, grabbed, or slapped, etc. If yes, who, how often and what happened?

What are your expectations of relationship counselling?

Please make at least three suggestions as to something you could personally do to improve the relationship:

Relationship counselling Intake form

Welcome to Turning Tides Life Coaching and Counselling. Please take a moment to review and complete this form to the best of your ability. If you have any questions please be sure to ask your counsellor. Each Individual in Relationship Counselling will complete and submit their own form.