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Intake Form Couple TherapyFaber Reklame2018-04-14T08:06:44+02:00

Intake Form Couple Therapy

Administrative details
Name and surname*
Address*
Postal code*
Town / City*
Telephone number*
E-mail
Date of Birth*
Marital status*
Place of work / occupation*
GPs name and address*
Personal details
Please could you describe your reason for therapy?
Please could you describe the cause(s) of the problem(s)?
What are your partner’s ideas about the cause(s) of the problem(s)?
Who took the initiative to start therapy? (Yourself, your partner, GP, someone else? )
Please could you write down which people in your network are important to you?
Hoe ernstig beoordeelt u zelf de klachten of problemen?
- Mild
- Serious
- Very serious
What would you like to achieve in the therapy?
Are there any other problems? (i.e. work, relationships, friends, finances)?
Have there been traumatic incidents that are related to your problem(s)?
Do you use alcohol? If so, how much/ how often?
Do you use drugs? If so, how much/ how often?
Do you have physical or emotional problems?
- Yes
- No
Which problems?
How long have you had these problems?
Have you seen any of the following?
- GP
- Therapist
- Another specialist
Have you been diagnosed?
- Yes
- No
By whom?
- MD
- Psychiatrist
- Psychologist
- Another specialist
Which diagnosis has been made?
Do you use medicines?
- Yes
- No
If yes, which medicines
Do you give me permission to ask your GP for information?
- Yes
- No
Do you give me permission to inform your GP about the start and completion of the therapy?
- Yes
- No
Children
Do you have children from your current relationship?
- Yes
- No
Do you have children from a previous relationship?
- Yes
- No
Name first child
Are you the biological parent?
- Yes
- No
Male / Female
- Male
- Female
Age
Name second child
Are you the biological parent?
- Yes
- No
Male / Female
- Male
- Female
Age
Name third child
Are you the biological parent?
- Yes
- No
Male / Female
- Man
- Vrouw
Age
Name fourth child
Are you the biological parent?
- Yes
- No
Male / Female
- Male
- Female
Age
Name fifth child
Are you the biological parent?
- Yes
- No
Male / Female
- Male
- Female
Age
Do any of your children suffer from problems?
- Yes
- No
Which problems?
Parental Family
Are your parents alive?
- Yes
- No
Father
- Yes
- No
Age
Deceased at the age of..
Mother
- Yes
- No
Age
Deceased in...?
Deceased at the age of...?
What is / was your father’s occupation?
What is / was your mother's occupation?
How many brothers and sisters do you have?
How many brothers?
How many sisters?
De hoeveelste was u in de kinderrij?
Further information about your family that could be important for your therapy

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