Blended Family Assessment Intake Questionnaire
General Information
Client Name
Date
Phone
Email
Primary Address
Family Members
Adult 1 Name
Adult 1 Relation to Children
Adult 2 Name
Adult 2 Relation to Children
Children (List all children in the home and their ages)
Blending Family Details
Length of Current Relationship/Marriage
How long has the blended family lived together?
Custody/Visitation Arrangements
Are there children who spend time in multiple households?
Yes
No
Brief description of previous family situations (e.g., divorce, loss, remarriage)
Current Family Dynamics
What strengths do you see in your blended family?
What challenges is your family currently facing?
Have there been any recent changes affecting your family? (e.g. moving, new siblings)
Describe any ongoing conflicts or sources of stress
Goals for Assessment/Counseling
Main concerns or issues
What are your hopes for this process?
Any other information you would like to share