ALCS Couple Intake Form
Thank you for choosing Abundant Life Counseling Services, P.A. So that we can better assist you, please fill out this form as fully and openly as possible. All information is held in strictest confidence within legal limits. If certain questions do not apply to you, you can leave them blank.
Who is your ALCS counselor?
*
Kerry Williamson, MA, LPC-S, LMFT-S, CST
Carolyn Dixon, MSW, LCSW
Rachelle Honohan, MSW, LCSW-S
Regina Gray, MS, LPC
Nicole Parker, MA, LPC
Linlee Carbajal, MS, LPC
Julie O'Brien, MA, LPC-Associate Supervised by: Kerry Williamson, MA, LPC-S, LMFT-S, CST
Identifying Information
Full Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
May we call you at the phone number(s) provided above? Check all that apply.
Yes, you can call my cell phone
Yes, you can call my work phone
Yes, you can call my home phone
Please do not call me
May we leave you a voicemail at the phone number(s) provided above? Check all that apply.
Yes, you can leave a voicemail on my cell phone
Yes, you can leave a voicemail on my my work phone
Yes, you can leave a voicemail on my home phone
Please do not leave a voicemail
Gender
Age
Race & Ethnicity
Occupation
Religion / Spirituality
Email Address
*
example@example.com
May we email you at this email address?
*
Yes
No
How did you hear about us?
Current Marital Information
If you are currently married, please fill out the information below about your spouse.
My relationship status is...
Never married
Married
Divorced
Separated
Widowed
Other
Name of Spouse
First Name
Last Name
Date of Marriage
-
Month
-
Day
Year
Date
Spouse's Address (if different from yours)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
Date of Birth
-
Month
-
Day
Year
Date
Gender
Age
Race & Ethnicity
Occupation
Religion / Spirituality
Is your spouse willing to come in for counseling?
Yes
No
Unsure
Have you ever separated from your current spouse?
Yes
No
When?
Have either of you filed for divorce?
Yes
No
When?
How old were you both when you got married?
How long did you know your spouse before marriage?
Length of steady dating with spouse?
Length of engagement?
Previous Marital History
Self
Name of Previous Spouse
Date of Marriage
Date of Divorce/Death
1
2
3
4
Spouse
Name of Previous Spouse
Date of Marriage
Date of Divorce/Death
1
2
3
4
Your highest level of education completed
GED
High school diploma
College degree
Graduate degree
Degree(s)
Have you had any coursework related to Mental Health or Psychology? If yes, describe briefly:
Your spouse's highest level of education completed
GED
High school diploma
College degree
Graduate degree
Degree(s)
Has your spouse had any coursework related to Mental Health or Psychology? If yes, describe briefly:
Children
Child's Name
Age
Gender
Father's / Mother's First Name
1
2
3
4
5
6
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Personal Information
Are religious or spiritual issues important in your life?
Yes
No
Are you currently attending a church?
Yes
No
What is your denomination preference?
Who referred you to our center?
May we acknowledge your referral? (your name will be kept confidential)
Yes
No
Health Information
In brief, how would you rate your health?
Ex: excellent, good, fair, bad, poor
Have you gained or lost weight in the past three months?
Yes, I have gained weight.
Yes, I have lost weight.
My weight is the same.
How much weight have you gained / lost?
Ex: 10 lbs gained
List all important present or past illnesses, injuries or handicaps:
How many hours do you sleep each night, on average?
Do you experience food cravings?
Yes
No
For which types of foods?
How would you rate your diet?
Very Healthy
Healthy
Average
Needs Improvement
Poor
Are you currently taking medications?
Yes
No
Please list the medications you are taking.
Medication
Dosage
Frequency
Purpose
Physician
1
2
3
4
5
6
Primary Care Physician Name
Physician's Phone Number
-
Area Code
Phone Number
Date of last physical exam
-
Month
-
Day
Year
Date
Date of last routine check-up
-
Month
-
Day
Year
Date
Are you currently using any drugs for recreational purposes?
Yes
No
Are you currently consuming alcohol for recreational purposes?
Yes
No
Please list your drug and/or alcohol use.
Substance
Amount
Frequency
1
2
3
4
5
6
Do you have any current or past legal issues?
Yes
No
Please briefly explain.
Have you ever been arrested?
Yes
No
Please briefly explain.
Have you recently suffered any personal, business or financial loss?
Yes
No
Please briefly explain.
Have you ever been the victim of a crime?
Yes
No
Please briefly explain.
Have you ever been abused?
Yes
No
When did this happen?
For Women
Are you pregnant?
Do you have a regular menstrual cycle?
Have you ever terminated a pregnancy?
Have you ever miscarried?
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Personal Concerns
What are you seeking help for in your marriage?
How much are you troubled by this?
Constantly
Often
Somewhat
Not very much
Comments concerning this problem
Have you been in counseling before?
*
Yes
No
First time in counseling: Who was the counselor?
First time in counseling: What was the problem?
First time in counseling: How many sessions, when, over what period of time?
First time in counseling: What were the results?
Second time in counseling: Who was the counselor?
Second time in counseling: What was the problem?
Second time in counseling: How many sessions, when, over what period of time?
Second time in counseling: What were the results?
Third time in counseling: Who was the counselor?
Third time in counseling: What was the problem?
Third time in counseling: How many sessions, when, over what period of time?
Third time in counseling: What were the results?
Have you ever filed a complaint against a mental health professional?
Yes
No
Please explain.
Thoughts and Behaviors
Please check how often the following thoughts occur to you:
Never
Rarely
Sometimes
Frequently
1. Life is hopeless.
2. I am lonely.
3. No one cares about me.
4. I am a failure.
5. Most people don't like me.
6. I want to die.
7. I want to hurt someone.
8. I am so stupid.
9. I am going crazy.
10. I can't concentrate.
Please check how often the following thoughts occur to you:
Never
Rarely
Sometimes
Frequently
11. I am so depressed
12. God is disappointed.
13. I can't be forgiven.
14. Why am I so different?
15. I can't do anything right.
16. People hear my thoughts.
17. I have no emotions.
18. Someone is watching me.
19. I hear voices in my head.
20. I am out of control.
Please comment (e.g., examples, frequency, duration, effects on you) about each of the above thoughts that occur frequently or are of concern to you.
Symptoms
Please check the behaviors and symptoms that occur more often than you would like:
*
Aggression
Alcohol Dependence
Anger
Antisocial Behavior
Anxiety
Avoiding People
Chest Pain
Depression
Disorientation
Distractibility
Dizziness
Drug Dependence
Eating Disorder
Elevated Mood
Fatigue
Hallucinations
Heart Palpitations
High Blood Pressure
Hopelessness
Impulsivity
Irritability
Judgment Errors
Loneliness
Memory Impairment
Mood Shifts
Panic Attacks
Phobias/Fears
Recurring Thoughts
Sexual Difficulties
Sick Often
Sleeping Problems
Speech Problems
Suicidal Thoughts
Thoughts Disorganized
Trembling
Worrying
Withdrawing
Other
Please give examples of how each of the symptoms that you checked impairs your ability to function (i.e., socially, emotionally, occupationally, physically, etc.).
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Specific Personal Concerns
Please check any of the following that are currently troubling you:
*
Abortion
Abandonment Issues
Adoption
Addiction(s)
Alcoholism
Anger
Anxiety
Apathy
Bitterness/Resentment
Burnout/Stress
Change of Lifestyle
Child Abuse
Children/Discipline
Children/School
Children/Rebellion
Communication
Confusion
Crisis/Conflict
Death of a Loved One
Depression
Divorce
Eating Disorder
Envy/Jealousy
Family Issues
Father Issues
Fear of Rejection
Fear (general)
Finances/Debt
Forgiveness
Frustration
Gambling
Guilt
Health/Medical
Honesty
Infidelity
In-Laws
Job Problems
Legal Issues
Loneliness
Loss of Appetite
Loss of Control
Loss of Concentration
Loss of Energy
Loss of Memory
Loss of Sleep
Loss of Temper
Loss of Trust
Marriage
Medication/Drugs
Mid-life
Mother Issues
Obsessive Thoughts
Obsessive Actions
Panic Attacks
Physical Abuse
Pornography Use
PMS/Hormones
Religion/Faith Issues
Same-Sex Attraction
Self-Injury (cutting, burning, etc.)
Separation
Sexual Abuse/Rape
Sexual Addiction
Sexual Compulsion
Sexual Issues (other)
Single Parent
Singleness
Spouse Abuse
Substance Abuse
Suicidal Thoughts
Self-Esteem
Rejection
Violence/Rage
Withdrawal
Worry
Other
Other specific areas of concern
Of the above, please identify your top three areas of current concern. How long have these problems existed?
Indicate everything that you have experienced in the past three years:
*
Adopting children
Affair
Blended family
Changes in marital status
Death of a spouse/partner/friend
Death of a family member
Family problems
Financial problems
Fostering children
Legal problems
Loss of job
Major illness or injury (self)
Major illness or injury (family)
Marriage problems
Move to another city/state/country
None of the above
Current Issues
Rate your current level of marital happiness by checking the number in the box below that corresponds with your current feelings about your relationship.
1
Completely Unhappy
2
Extremely Unhappy
3
Very Unhappy
4
Fairly Unhappy
5
Content
6
Fairly Happy
7
Happy
8
Very Happy
9
Extremely Happy
10
Completely Happy
Check one:
What are your top three most frequent arguments in your marriage about?
Have you/your spouse ever threatened to divorce or separate due to current or past issues?
Yes
No
Please explain.
Have you/your spouse ever consulted a lawyer about divorce?
Yes
No
Please explain.
Sexual Inventory
Rate your current level of sexual satisfaction in your marriage by checking the number in the box below that corresponds with your current feelings about it.
1
Completely Unhappy
2
Extremely Unhappy
3
Very Unhappy
4
Fairly Unhappy
5
Content
6
Fairly Happy
7
Happy
8
Very Happy
9
Extremely Happy
10
Completely Happy
Check one:
Currently, how often do you and your spouse have sex?
Do you and your spouse have open communication about sex?
How supportive are your parents concerning your marriage?
How supportive are your in-laws concerning your marriage?
Did your immediate family members attend your wedding?
Yes
No
Please explain.
Do you have relationships you do not maintain with any family members?
Yes
No
Please explain.
Emergency Contact
Whom should we contact in case of emergency?
Full Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
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