Couples Intake Form

Please take a moment to complete & submit the following information. PLEASE NOTE, if you are scheduled for couple's counseling, EACH PARTNER must complete & submit an intake. Should we NOT receive the information from both partners prior to your first appointment, we will take the time to complete the intake in office during your scheduled time.

PERSONAL INFORMATION
Therapist you are confirmed to meet with:*
- Jimmy Rosen, MFT
- Lindley Kunce, PC
Name*
First Last
Partner's Name*
First Last
Address*
PO Box City State / Province / Region ZIP / Postal Code Country
Date of birth - month, day, year*
Phone*
Email address*
May we contact you via text?*
- Yes
- No
- I prefer email
- I prefer phone call
Relationship Status*
- Single
- Engaged
- Married
- Divorced
- Partners
How long have you been in relationship/married?
Number of children
List children names and ages
PRESENTING PROBLEM
Who referred you to JHFS?*
Reason for referral.*
Briefly describe presenting problem (why you have made an appointment)*
How long has problem occured?*
Briefly outline your goals for therapy*
Briefly describe previous treatment for this issue. Who did you see before and for how long?*
Briefly describe any relationship strengths:*
Please list any medications you are currently taking and for what purpose as it relates to these issues
Who is the prescribing doctor?
PERSONAL HISTORY
I am currently receiving individual counseling*
- Yes
- No
If YES, please list provider and reason for being in individual counseling.
I have received individual counseling in the past.*
- Yes
- No
If YES, please list provider and reason for being in individual counseling.
Do you have personal history of suicide attempt/ideation?*
- Yes
- No
If YES, please list dates and briefly describe history
Do you have personal history of mental health hospitalization?*
- Yes
- No
If YES, please list dates and briefly describe history
PERSONAL HISTORY - habits, substance abuse/addictions
Are you worried about any of your habits?*
- drugs/alcohol
- sex or porn
- food
- phone/social media
- spending
- gambling
- OTHER
- NONE
Is your partner worried about any of your habits?
- Yes
- No
Are you worried about any of your partner's habits?
- Yes
- No
Which habits of your partner's make you worried?*
- drugs/alcohol
- sex or porn
- food
- phone/social media
- spending
- gambling
- NONE
Do you have a personal history with addictions?*
- drugs/alcohol
- sex or porn
- food
- OTHER
- NONE
Have you received previous OUTPATIENT treatment for this issue?
- Yes
- No
If YES, please list dates, facility and outcomes.
Have you received previous INPATIENT treatment for this issue?
- Yes
- No
If YES, please list dates, facility and outcomes.
Do you currently engage is substance use?*
- Yes
- No
If YES, list substances and frequency of use (i.e. multiple times/day, daily, weekly, monthly)
Do you or your partner feel that your use impacts the relationship?*
- Yes
- No
Does your partner currently engage is substance use?*
- Yes
- No
If YES, list substances and frequency of use (i.e. multiple times/day, daily, weekly, monthly)
Do you feel your partners use impacts the relationship?*
- Yes
- No
Date of last use
MM slash DD slash YYYY
PERSONAL HISTORY - sexual trauma
Do you have personal history of sexual trauma?*
- Yes
- No
If YES, please list dates/ages and briefly describe history... . to the best of your ability
Have you received previous counseling for this issue?
- Yes
- No
If YES, please list dates, providers and outcomes
PERSONAL HISTORY - family violence
Do you have personal history of family violence - verbal abuse or physical abuse?*
- Yes
- No
If YES, please list dates/ages and briefly describe history.... to the best of your ability
Have you received previous counseling for this issue?
- Yes
- No
If YES, please list dates, providers and outcomes
Please list any additional information you feel is important for therapist to know
RELATIONSHIP HISTORY
Affair history in relationship?*
- Yes
- No
Name of partner who had an affair.
When did affair occur and for how long?
Has affair been disclosed?
- Yes
- No
Date of disclosure
MM slash DD slash YYYY
Is the affair ongoing?
- Yes
- No
Have you received previous couples counseling for this issue?
- Yes
- No
If yes, please indicate when you received counseling, for how long and the provider
Is there relational history of domestic violence?*
- Yes
- No
Who engages in violent behaviors
- Partner
- Self
- Both
Is domestic violence ongoing?
- Yes
- No
Has there been treatment for issue?
- Yes
- No
If yes, please indicate if, when, where you received couples counseling for this issue
Partner history of substance abuse?*
- Yes
- No
Is partner currently abusing substances?*
- Yes
- No
If yes, please indicate substance(s) and frequency. Please describe impact on relationship functioning.
Please outline relationship goals - in what ways do you hope your couples relationship will be different as a result of therapy?*
VIDEO TAPING
Video taping will sometimes be utilized to enhance our therapeutic services. It is considered the gold standard for treatment and is a part of training.Video will be reviewed by therapist and is confidential. Clients reserve the right to refuse and/or revoke consent to video tape sessions at any time, without consequence.
I understand:
I understand:
- Video taping is a common practice in effective treatment
- I have right to refuse/revoke consent at any time, without consequence
- My therapist will further discuss video taping at time of service
PAYMENT AGREEMENT
I have read, understand & authorize the following payment policies (checking the boxes below indicates approval response ("yes"):*
- Credit card will be held on file and charged accordingly on dates of service
- Late cancellations (less than 24 hours) will yield a full fee payment for hour
- I will be charged full payment for "no show" sessions
- I authorize payments for services, late cancellations and no show fees accordingly
Please provide the following credit card information to be kept on file: 1. credit card number 2. exp date 3. cvv 4. zip code*
Additional info you feel is important for your therapist to know
Additional questions you have regarding the counseling process
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Name
This field is for validation purposes and should be left unchanged.

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Couples Intake Form

PERSONAL INFORMATION

PRESENTING PROBLEM

PERSONAL HISTORY

PERSONAL HISTORY - habits, substance abuse/addictions

PERSONAL HISTORY - sexual trauma

PERSONAL HISTORY - family violence

RELATIONSHIP HISTORY

VIDEO TAPING

PAYMENT AGREEMENT