Marriage and Individual Counseling Form

Marriage and Individual Counseling Form

Personal Information

Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Emergency Contact
Emergency Contact
First
Last
Do we have permission to contact you regarding follow-up appointments?
Prior to today, have you been to our office?
How did you hear about us?
Race
Marital Status
Income Level
Rate your health
Have you had any recent weight changes?
How do you sleep at night?
Your Physician
Your Physician
First
Last
Are you presently taking prescribed medication?
Have you used drugs other than for medical purposes?
Have you ever had psychotherapy or counseling before?
If yes, please list name of therapist or counselor:
If yes, please list name of therapist or counselor:
First
Last