Your Name: Your DOB:



[pic] COUPLE’S CONTACT

Partner 1: Birthdate

First Middle Last

Address City Zip

Occupation: Employer:

Gender Identification/s:

Home Phone: Okay to leave message? Y N

Cell Phone: Okay to leave message? Y N

Work Phone: Okay to leave message? Y N

Partner 2: Birthdate

First Middle Last

Address City Zip

Occupation: Employer:

Gender Identification/s:

Home Phone: Okay to leave message? Y N

Cell Phone: Okay to leave message? Y N

Work Phone: Okay to leave message? Y N

RELATIONSHIP STATUS

Single Married Divorced Committed Relationship

How long have you been together as a couple?

Sexual Orientation/s:

Do you reside together? Y N

Have you ever separated? Y N

FAMILY

Please list below all children from this or previous marriages/relationships (include biological, adopted, foster and step children living in your households or not)

|Name |Age |Gender |Relationship |Do you have custody? |

| | | | |□ Yes □ No |

| | | | |□ Yes □ No |

| | | | |□ Yes □ No |

| | | | |□ Yes □ No |

| | | | |□ Yes □ No |

THERAPY

Briefly describe why you are seeking therapy:

HEALTH

Have either of you ever been hospitalized for depression, suicidality or other psychological reasons?

|Who |Setting |Approximate dates |Reason |

| | | | |

| | | | |

Please list any past health challenges that have significantly impacted your relationships.

Medical History (Partner 1):

|Current Health Challenge |Treating Physician |Medication |

| | | |

| | | |

Please list any past health problems that have significantly impacted you relationships.

Medical History (Partner 2):

|Current Health Problem |Treating Physician |Medication |

| | | |

| | | |

REFERRAL SOURCE

| |Self | |Employer |

| |Primary Physician | |Court |

| |Psychiatrist | |Friend |

| |Other Mental Health Professional | |Colleague |

| |School Counselor | |Family Member |

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