Individual Intake FormPart 2 Personal Information (continued) Today's Date * MM DD YYYY Name (continued) * First Name Last Name Marital Status Marital/Relationship Status Married Live with partner Single Separated/Divorced Widowed Same Sex Partner Comments regarding stresses in current or previous marriage(s)/relationship(s). If you have bad problems in the past, what do you think caused those relationships to end? Have you ever been abused mentally or physically by a romantic partner? Yes No Does this apply to your current relationship? Yes No Do you feel safe? Yes No Employment / Education Information Check all that apply. Employed Retired Disabled Student Homemaker Unemployed If/When employed, what type of work do you do? Current employer name. Years on current job. Highest degree completed in school. Highschool Grad Trade School Degree/Certification(s) Associates' Degree Undergraduate Degree Masters' Degree PhD Other Health / Medical Information Please list significant medical problems/conditions, and indicate if you are receiving treatment for them. Do any of these problems affect your everyday life? Yes No If Yes, please explain. Briefly describe any surgeries or hospitalizations for serious illness or injuries. (i.e. What, where, when, etc.) Have you ever blacked out/lost consciousness and/or experienced any type of serious head injury or trauma? Yes No If so, please indicate when and what happened. List all medications that you currently use. Name of medication, dosage and times per day, reasons for meds. Name of Medication Prescriber Name of Primary Care Physician (PCP) Additional Information Please describe anything else you would like me to know. Thank you for taking the time to fill out this intake form. Your information will be kept confidential. Feel free to visit the Home page for more information or Contact to reach me with any questions. End of Intake Form.Click Submit to complete the form.
