Marriage Counseling & Family Therapy

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Individual Intake

Individual Intake

We appreciate you taking the time to complete this online form prior to your first session. Please be sure to wait until form is sent before you close the page, otherwise the form may not be received. Thank you.

PERSONAL INFORMATION
Name*
First Last
Name of Therapist
- Charlotte DiPrisco, LPC
- Jimmy Rosen, MFT
- Laura Santomauro, LMFT
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?*
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 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
Please list personal strengths:*
PERSONAL HISTORY - substance abuse/addictions
Do you have a personal history with addictions?*
- drugs/alcohol
- sex or porn
- food
- OTHER
- NONE
Have you received previous treatment for this issue?
- Yes
- No
If YES, please list dates, facility and outcomes.
Are you currently using substances?*
- Yes
- No
Please list all substance you are currently using and frequency of use (i.e. multiple times/day, daily, weekly, monthly)
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
RELATIONSHIP HISTORY
I am currently in a committed relationship.*
- Yes
- No
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
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
Credit Card Information - this is a HIPPA compliant secure site*
Please include: 1. credit card number 2. expiration 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
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

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