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?_________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

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How long together/ married:_______________________________________

Children together (ages and genders): ___________________________________________________________

__________________________________________________________________________________________

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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):

__________________________________________________________________________________________

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Alcohol and drug abuse in home: _______________________________________________________________

__________________________________________________________________________________________

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Other addictions (i.e. sexual, food, computer, internet, gaming):_______________________________________

__________________________________________________________________________________________

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Suicidality or significant mental health concerns in either partner: _____________________________________

__________________________________________________________________________________________

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Other Challenges (i.e.trauma, loss, social, legal, financial, extended family, cultural):

__________________________________________________________________________________________

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Previous couples or individual therapy (specify recipient):___________________________________________

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Outcome:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Current individual therapy and therapist (specify recipient):__________________________________________

__________________________________________________________________________________________

Prescription Medication (specify recipient, name, dose, current/past duration):

Recipient Drug Dose Duration

__________________________________________________________________________________________

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Prescribing physician contact information:________________________________________________________

__________________________________________________________________________________________

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Client(s) Signature

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Date

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