couples counseling initial intake form - padma desai · couples counseling initial intake form 1...

Padma Desai Counseling and Consulting, LLC Princeton Area Multicultural Counseling and Consulting 103 Carnegie Center Drive, Suite 300 Princeton, NJ 08540 T (973) 214-8094 padmadesai.com [email protected]

Couples Counseling Initial Intake Form

1

Please provide the following information and answer the questions below. Please note:

information you provide here is protected as confidential information

My Name: _________________________________________________________________

My Birth Date: _______________________Gender: ________________________________

My Partners Name: __________________________________________________________

My Partners Birth Date: ________________Gender: ________________________________

My Address:________________________________________________________________

__________________________________________________________________________

My Partners Address:

__________________________________________________________________________

__________________________________________________________________________

My Home Phone: May we leave a message? □ Yes □ No

My Cell/Other Phone: May we leave a message? □ Yes □ No

My Partners Home Phone: May we leave a message? □ Yes □ No

My Partners Cell/Other Phone: May we leave a message? □ Yes □ No

My E-mail: ______________________________________________________________________

My Partners E-mail:_______________________________________________________________

*Please note: Communication via email is NOT a HIPAA (Health Insurance Portability and

Accountability Act of 1996) compliant form of communication. Please do not send any Protected

Health Information (PHI) via email. Any email sent to the offices of Padma Desai Counseling and

Consulting LLC containing PHI will NOT be responded to.

Would you like to receive appointment reminders? Email (requires email address:_____________________________________________) Text (requires cell phone number and carrier:__________________________________) Phone Call (requires home phone number:____________________________________)

mailto:[email protected]



2

None:_________________________________________________________________ )

Referred by (if any): __________________________________________________________

May thank the referral source via a letter for referring you to us? (You will have to sign a Release

of Information) □ Yes □ No

Relationship Status: (check all that apply)□ Married □ Separated □ Divorced

□ Widowed □ Living together □ Living apart

Length of time in current relationship: __________________ (months/years) Children From Current Relationship: Name:__________________ Age: _________________ Gender:______________ Name:__________________ Age: _________________ Gender:______________ Name:__________________ Age: _________________ Gender:______________ Children From Previous Relationship: Name:__________________ Age: _________________ Gender:______________ Name:__________________ Age: _________________ Gender:______________ Name:__________________ Age: _________________ Gender:______________ As you think about the primary reason that brings you here, how would you rate its frequency and your overall level of concern at this point in time? Concern □ No concern □ Little concern

□ Moderate concern □ Serious concern

□ Very serious concern




3

Frequency □ No occurrence □ Occurs rarely

□ Occurs sometimes □ Occurs frequently

□ Occurs nearly always

What do you hope to accomplish through counseling?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________ What have you already done to deal with the difficulties?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

What are your biggest strengths as a couple? _________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________ Please rate your current level of relationship happiness by circling the number that corresponds with your current feelings about the relationship. 1 2 3 4 5 6 7 8 9 10 (extremely unhappy) (extremely happy) Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does.

________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________




4

Have you received prior couples counseling related to any of the above problems? □ Yes □ No If yes,when:_____________________________Where_____________________________ By whom: ______________________________ Length of treatment: _________________

Concerns Explored:___________________________________________________________________ ___________________________________________________________________________________ What was the outcome (check one)? □ Very successful □ Somewhat successful □ Stayed the same □ Somewhat worse □ Much worse Do you and/or your partner have a Primary Care Physician or other Physician? □ Yes □ No

Name of My Primary Care Physician:__________________________________________________________________

Telephone: _________________________________________________________________ Fax: _______________________________________________________________________

Name of My Partner’s Primary Care Physician:___________________________________________________________________

Telephone: _________________________________________________________________ Fax: ______________________________________________________________________

Are you and/or your partner prescribed medications by your Primary Care Physician or other Physician? □ Yes □ No If yes, for what condition? Myself: _________________________________________________________________ My Partner: _____________________________________________________________ If yes, what the names and dosages of your medications” Myself: _________________________________________________________________




5

My Partner: _____________________________________________________________

Have either you or your partner been hospitalized for a mental illness? □ Yes □ No Myself: _________________________________________________________________ My Partner: _____________________________________________________________ Have either you or your partner experienced suicidal thoughts or attempted suicide? □ Yes □ No Myself: _________________________________________________________________ My Partner: _____________________________________________________________ Have you and/or your partner experienced homicidal thoughts or attempted homicide? □ Yes □ No Myself: _________________________________________________________________ My Partner: _____________________________________________________________ Have either you and/or your partner been in individual counseling before? □ Yes □ No Myself: _________________________________________________________________ If so, give a brief summary of concerns that you addressed.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________ My Partner: _____________________________________________________________ If so, give a brief summary of concerns that you addressed.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________




6

Are you and/or your partner currently being treated by a Psychiatrist? □ Yes □ No

Name of My Psychiatrist: ______________________________________________________

Address:____________________________________________________________________

Telephone: ____________________________________________Fax:__________________

Name of My Partner’s Psychiatrist:_______________________________________________

Address:____________________________________________________________________

Telephone: _________________________________________________________________

Fax: _____________________________________________________________________ Have you and/or your partner been prescribed psychiatric medications as an adjunct to your individual counseling before? □ Yes □ No If yes, what the names and dosages of your medications” Myself: _________________________________________________________________ My Partner: _____________________________________________________________

Have you and/or your partner been compliant with the recommendations/medications prescribed by you psychiatrist?

Myself: _________________________________________________________________ My Partner: _____________________________________________________________




7

Do you and/or partner drink alcohol? □ Yes □ No If yes, how often and what type of alcohol? Myself: _________________________________________________________________ My Partner: _____________________________________________________________ Do you and/or partner use illicit drugs? □ Yes □ No If yes, how often and what drugs? Myself: _________________________________________________________________ My Partner: _____________________________________________________________ Have you and/or partner struck, physically restrained, used violence against or injured the each other? □ Yes □ No If yes for either, who, how often and what happened. Myself: _________________________________________________________________ My Partner: _____________________________________________________________

Have you ever been in an inpatient facility for mental health and/or substance use disorders? □ Yes □ No If yes, please provide dates and names of facilities:

___________________________________________________________________________

______________________________________________________________________________________________________________________________________________________




8

Family History of Mental Health/Substance Abuse:

Family Member Diagnosis Treatment History Treatment Response

Has either of you threatened to separate or divorce (if married) as a result of the current relationship problems? If yes, who? ___Me ___Partner ___Both of us If married, have either you or your partner consulted with a lawyer about divorce? If yes, who? ___Me ___Partner ___Both of us Do you perceive that either you or your partner has withdrawn from the relationship? If yes, which of you has withdrawn? ___Me ___Partner ___Both of us How frequently have you had sexual relations during the last month? ________times

How enjoyable is your sexual relationship? (Circle one) 1 2 3 4 5 6 7 8 9 10 (extremely unpleasant) (extremely pleasant) How satisfied are you with the frequency of your sexual relations? (Circle one) 1 2 3 4 5 6 7 8 9 10 (extremely unsatisfied) (extremely satisfied)




9

What is your current level of stress (overall)? (Circle one) 1 2 3 4 5 6 7 8 9 10 (no stress) (high stress) What is your current level of stress (in the relationship)? (Circle one) 1 2 3 4 5 6 7 8 9 10 (no stress) (high stress) Rank order the top three concerns that you have in your relationship with your partner (1 being the most problematic):

1. _____________________________________________________________________

2. _____________________________________________________________________

3. _____________________________________________________________________

Thank you for taking the time to complete this!


couples counseling initial intake form - padma desai · couples counseling initial intake form 1...

Documents