Family Counseling Intake Form
Parent/Guardian Name
Relationship to Family
Phone Number
Email Address
Address
City
State
Zip Code
Family Members (Names & Ages)
Presenting Concerns/Reasons for Seeking Counseling
Goals for Counseling
Previous Counseling or Mental Health Services?
Yes
No
If yes, please describe
Is there any history of trauma, abuse, or significant life events?
Medical or Psychiatric Conditions in Family Members
Anything else you wish your counselor to know?