Relationship Intake Questionnaire

Liberated Counseling Intake Questionnaire

Please complete the following questionnaire before your first appointment. This helps me complete anintake assessment and get an overall picture of your current struggles and strengths. While some of these questions may seem like asking a lot of information, most of these questions are required by the norms of the counseling field in order to provide you the best possible service. Thanks!
Name of Person filling out this form:
Reason for Seeking Counseling:
Presenting Concerns (please check all that apply)

Suicidal ThoughtsSocial StrugglesParent / Child ConflictProblems with Child / Children:
Physically Abusive to SelfShy, Uneasy with OthersEmployment / School IssuesWithdrawn
Defiance / OppositionalityDrug / Alcohol Use ConcernsAnxiety / WorriesConfusionAddictionEating Habits / ProblemsDepressionDifficulty Being AlonePerfectionismLying FrequentlyFatigueGuilt/ShameHearing Voices / HallucinationsMemory / Concentration Problems
Motivation Reduced / AbsentMood SwingsUnwanted Behavior/HabitsPassive / UnassertiveObsessive ThoughtsPanic (or Anxiety) AttacksPhysical AbuseLow Self-EsteemLiving ArrangementsLegal ProblemsMoney Management IssuesWeight ChangeIncreaseDecreaseSexual AbuseRelationship / Marital IssuesParenting IssuesSleep ProblemsTrauma / PTSDExistential / Spiritual StrugglesCutting / Self-HarmStruggles Attaching / Having RelationshipsDivorce / SeparationGrief and LossComing out / GLBTQ ConcernsCommunication StrugglesIndividual Sexuality ConcernsUnusual ThoughtsBody Image ConcernsCouple Sexuality ConcernsPersonal Pleasure ConcernsAnger / Aggression / ViolenceRelationship Pleasure Concern
Prior Behavioral Health Experiences
1. Outpatient Counseling (Dates, Clinic / Therapist, Helpful?)
2. Intensive Treatment: IOP, Day or Residential Treatment, Hospitalization (Dates Clinic / Therapist, Helpful?)
Medical History (current and in the past)
Medical Conditions in the last year
Chronic Illnesses
Surgeries
Head Injuries (diagnosed or otherwise)
Disabilities (physical or developmental)
Allergies
Advanced Directives
Medications (Name, Dose / Frequency, Start, End, Reason, Prescriber)
Substance Use History:
1. Alcohol Use History (Type, Quantity, Frequency, Periods of Heavier Use)
2. Tobacco Use History (Type, Quantity, Frequency, Periods of Heavier Use)
3. Cannabis Use History (Type, Quantity, Frequency, Periods of Heavier Use)
4. Caffeine Use History (Type, Quantity, Frequency, Periods of Heavier Use)
5. Other Non Prescribed Drug Use History (Type, Quantity, Frequency, Periods of Heavier Use)
Vocational History

1. Education History
Highest level of education to date:
Current School / Field of Study
2. Employment History
Are you currently Employed?

YesNo
Job Title
Do you have any concerns about employment?

YesNo
What are your Concerns?
3. Military Experience
Have you been in any branch of the military?

YesNo
Branch
Position
Reason for Discharge
General Relationship Questions
How long have you and your partner been together?
What initially attracted you to your partner?
What was the beginning of your relationship like and how long did this phase last?
What are some of the strengths in your relationship?
Describe your sexual relationship. What do you find most satisfying about it? What don't you like about it? How has your sexual relationship changed since you were first together?
Should be Empty: