Adult/Couple Intake Form - Alvarado Consulting Group

This is a confidential questionnaire that will provide me with information that will be helpful in coaching or therapy. If there are questions that you would rather not answer, leave them blank. You will receive an email copy of your form upon completion that you can print out for yourself.

Name*

First Last

Birth Date*

Home Phone

Work Phone

Cell Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Referral Source

Emergency Contact

Emergency Contact Phone

Employer

Today's Date*

What made you seek therapy/coaching at this time?

If therapy/coaching is successful, how will you and/or your life be different? What are your therapy/coaching goals?

Name, ages and brief description of people living in your home:

Education (list degrees and courses of study):

Job History (name of employer, dates, position, degree of satisfaction):

Health History: Illnesses, Injuries, Surgeries

Health History: Current health issues

Health History: Current medications, reason, and name of prescribing physician

Health History: Do you have a problem with:

Family of Origin: Names, ages, brief descriptions:

You can draw the family tree on a sheet of paper and bring with you to the next session if you prefer.

What kind of relationship did you have with your mother?

What kind of relationship did you have with your father?

What kind of relationship did you have with your siblings?

What kind of relationship did you have with other significant members (stepparents, grandparents etc)?

Important Events in Childhood:

Important Events in Teenage Years:

What was the mood of the house?

Relationship History (choose the most important relationships):

Names, dates, brief descriptions of partner(s) and basic qualities of the relationship:

What are your intimacy issues, patterns, and trends?

Trauma History:

Have you ever been sexually or physically abused? By whom? When? How long have you known?

What Significant Losses have you experienced? When?

Have you ever made a suicide attempt? Please give details:

Describe yourself, including positive and negative traits:

Current Marriage/Relationship:

How long together?

How long married?

What was your initial attraction to your partner?

What do you currently like or appreciate about your partner?

What are the strengths or foundational aspects of your relationship?

What are the weaknesses of your relationship? What changes do you want to see?

Which of these issues are major sources of conflict for YOU:

In Your Marriage/Relationship, What Is:

Your Level of Commitment

Select a number from 1 to 5 where 1 is low and 5 is high.

Please enter a number from 1 to 5.

Your Level of Distress

Select a number from 1 to 5 where 1 is low and 5 is high.

Please enter a number from 1 to 5.

Your Level of Sexual Satisfaction

Select a number from 1 to 5 where 1 is low and 5 is high.

Please enter a number from 1 to 5.

Your Level of Emotional Satisfaction

Select a number from 1 to 5 where 1 is low and 5 is high.

Please enter a number from 1 to 5.

Describe your Sexual and Emotional Intimacy. What is/is not satisfying for you?

What happens when you fight? What are your triggers? Can you name the cycle?

How do you reconnect after an argument?

Check all of the statements that reflect what you DO and the way you FEEL when you and your partner are not getting along or fighting.

What I Feel:

What I Tend To Do:

What My Partner Tends to Do:

Previous Therapy/Coaching

Names, dates, type of therapy/coaching. Was it positive/negative/neutral?

Is there anything else that you want me to know?

Comments

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