Name
*
First Name
Last Name
Age
*
Date of Birth
*
MM
DD
YYYY
Sex
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Do you wish to be added to CCM's mailing list?
Yes
No
Phone
*
(###)
###
####
Occupation
*
Employer
*
For confidentiality purposes, how and when do you prefer to be reached?
*
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Number
*
(###)
###
####
Emergency Contact relationship to you
*
What language is spoken at home?
*
With whom are you presently living?
*
Parents
Spouse
Roommate
Alone
Other
Do you believe in God?
*
Yes
No
If you believe in God, how would you describe your relationship with Him?
*
If you do not believe in God, how would you describe your spirituality?
*
How long have you been married, cohabitating, separated or divorced?
*
Number of Marriages
Number of Children and their ages
Please list your family of origin (parents, guardians, siblings, spouses, significant others, etc.) and rate your relationship with them on a scale of 1-5 (1 being very weak; 5 being very strong)
*
Please list all other significant relationships/social supports currently present in your life.
*
What has led you to pursue counseling?
*
What would you like to experience that is different from what you are currently experiencing?
*
What are you hoping to gain from your counseling experience?
*
Have any concerns about you been identified by others?
*
When did your present concern begin to be a problem for you?
*
Where are your concerns causing the most problems for you? Check all that apply:
*
Please describe any significant or stressful life events that you have been experiencing (for example: economic problems, difficulty accessing health care, legal issues or crime, cultural issues, family conflict or lack of support, social problems, educational or occupational difficulties, housing problems, grief or bereavement):
*
Please rate the severity of your present concerns on the following scale. Check one:
*
Please rate your current level of relationship satisfaction on a scale of 1 (extremely unsatisfied)-10 (extremely satisfied):
*
Have you received prior couples counseling? If yes, please include when, where, length of treatment and problems treated.
*
If you have received couples counseling previously, was the outcome successful?
*
Very
Somewhat
No change
Got worse
I did not receive couples counseling previously
Whose idea was it to come to couples counseling this time?
*
What are your biggest strengths as a couple?
*
Please make at least 3 suggestions as to something you could personally do to improve the relationship regardless of what your partner does:
*
Have either you or your partner physically restrained, harmed or injured the other person (for example pushed, shoved, grabbed or slapped)? If yes: who, how often and what happened?
*
Do you perceive that either you or your partner has withdrawn from the relationship?
*
Yes, I have
Yes, my partner has
Yes, we both have
No, we have not
Have either of you threatened to separate/divorce as a result of the current relationship problems?
*
Yes, I have
Yes, my partner has
Yes, we both have
No, either of us have
If married, have either of you consulted with a lawyer about a divorce?
*
Yes, I have
Yes, my partner has
Yes, both of us have
No, we have not
We are not married
Have you or your partner ever emotionally or physically cheated on each other?
*
Yes, I have
Yes, my partner has
Yes, we both have
I am unsure of the answer to this question
No we have not
Please rate how satisfied you are with the frequency of your sexual activities on a scale 1-10 (1=extremely unsatisfied and 10=extremely satisfied):
*
Please rate how satisfied you are with the quality of your sexual activities on a scale 1-10 (1= extremely unsatisfied and 10=extremely satisfied):
*
Please rate your current overall stress level on a scale 1-10 (1=no stress, 10=extremely stressed):
*
Please rate your current level of stress in the relationship on a scale 1-10 (1=no stress, 10=extremely stressed):
*
Please indicate which of the following symptoms you are currently experiencing. Check all that apply:
*
Please use the space below to list any additional symptoms you are currently experiencing that are not listed above:
When did your symptoms start?
*
How often are you experiencing them?
*
How long do your symptoms last?
*
Have you ever suffered a traumatic experience?
*
Yes
No
If you checked "yes" and would like to, please explain below:
Would you like to discuss this traumatic experience with your counselor?
Yes
No
How would you rate your current physical health?
*
Date of last physical examination
*
Please list any past and current medical conditions/treatments:
*
Please list any medications (including over the counter) you are currently taking:
Please include dosage and reason for taking the medication.
Please list any previous hospitalizations for medical and psychiatric reasons:
Please include dates hospitalized and reason.
Please list names of any previous individual counselors or therapists, including dates you saw them and their contact number:
*
Do we have your permission to contact your previous counselor?
*
Yes
No
How do you feel about the results of your previous counseling?
If currently a student, please list your major and if you attend full-time or part-time.
Institution, University, or College:
What Is the highest level of education you have achieved:
*
How much influence does your religion/spirituality have on your day-to-day activity?
*
Please list any history of mental illness in your family, their relationship to you, and their diagnosis:
*
Please list your legal history (i.e. arrest history, DUI occurrences, incarcerations, etc.) as well as the dates/years in which they occurred:
*
Please list any substance use:
*
Please include name of substance, start date, last date used, amount, and frequency.
In the event that the currently appointed CCM counselor is not available to address the needs of the client, due to scheduling or other issues, CCM is authorized to release all intake information to another CCM counselor. This consent for release of information avoids any delays in beginning counseling and insures that the client receives appropriate care.
*
Typing your name below will be considered your electronic signature
First Name
Last Name
