Initial Clinical & Diagnostic Interview
NORTH BAY COUNSELING
CHARI PERCE, LMFT
INTAKE QUESTIONNAIRE - COUPLES
Date:__________________________ Referred by:________________________________________________
Client Names:
Partner #1:___________________________________ Age:_______ DOB:_______________ Sex:________
Phone (cell)_________________________ (home) ______________________ (work)__________________
OK to leave message? Yes No
Address:____________________________________City_________________State______ZIP____________
Currently employed: Yes No Employer:_______________________ Job Title:__________________
Partner #2:___________________________________ Age:_______ DOB:_______________ Sex:________
Phone (cell)_________________________ (home) ______________________ (work)__________________
OK to leave message? Yes No
Address:____________________________________City_________________State______ZIP____________
Currently employed: Yes No Employer:_______________________ Job Title:__________________
Emergency Contact: ___________________________________ Relationship: ________________________
Address: _________________________________________________________________________________
City: ___________________________________________________ State: _________ ZIP______________
Phone: ____________________________________
Current Concerns and Symptoms:______________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Precipitating Event/Why Now?_________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
How long together/ married:_______________________________________
Children together (ages and genders): ___________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Children from prior relationships (ages, genders, who is parent): ______________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
Who currently lives at home: __________________________________________________________________
__________________________________________________________________________________________
Physical, Sexual, Verbal Abuse History in Home (when, how often, how serious):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Alcohol and drug abuse in home: _______________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Other addictions (i.e. sexual, food, computer, internet, gaming):_______________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Suicidality or significant mental health concerns in either partner: _____________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Other Challenges (i.e.trauma, loss, social, legal, financial, extended family, cultural):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________
Previous couples or individual therapy (specify recipient):___________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Outcome:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Current individual therapy and therapist (specify recipient):__________________________________________
__________________________________________________________________________________________
Prescription Medication (specify recipient, name, dose, current/past duration):
Recipient Drug Dose Duration
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
Prescribing physician contact information:________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_____________________________________________
Client(s) Signature
_____________________________________________
Date
................
................
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