Family T.I.E.S. Counselling Intake Form

*This form is to be completed for the adult/parent only

 
Name: *
Name:
Birth Date: *
Birth Date:
Gender:
Home Address: *
Home Address:
Primary Phone Number: *
Primary Phone Number:
Alternate Phone Number: *
Alternate Phone Number:
Please provide name of responsible adult and phone number.
Please provide name, age, gender and notes per child if applicable.
Emergency Contact Information: *
Emergency Contact Information:
There are times when prior medical and psychological records may be requested with your written permission. Please make sure that all information given below is correct.
Date of Last Examination:
Date of Last Examination:
Are you now under doctor's care? *
Are you taking any medication? *
Have you ever been hospitalized for a physical illness? *
Have you ever been hospitalized for a mental illness?
If yes, please describe:
If yes, please describe:
Do you smoke? *
Do you drink? *
If yes, what kind and how often?
If Yes, describe (type of therapy, how many sessions)
City and Country
If divorced or separated, what year and what age?
Please provide: City/country, Relationship, Age and if applicable year deceased and cause of death.
Any history of Family Alcoholism, Substance Abuse, Domestic Violence, Sexual Addiction or Abuse? *
If yes, please describe:
If yes, please describe:
Describe (When/Do you have thoughts now?):