Family Therapy Intake Form
Family Information
Family Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Primary Contact Person
Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Other Family Members
Occupation
List all family members living in the household, including ages and relationships
Briefly describe the main concerns or challenges that the family is currently facing
What specific goals or outcomes would you like to achieve through family therapy?
Have any family members received counseling or therapy in the past? If yes, please provide details
Are there any significant medical or health-related issues within the family that the therapist should be aware of?
Insurance Information
Insurance Provider
Policy/ID Number
Group Number
Emergency Contact
Name
First Name
Last Name
Relationship to Family
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: