Marriage Counseling Form

Marriage Counseling Form – PDF Download

Name ______________________________ Phone (Home) ______________________________

Mobile _____________________________ Work ____________________________________

Date of Birth _________________________ SS#_____________________________________

Home Address _________________________________________________________________

City _______________________________ State __________  Zip  ________________

Occupation ____________________________________________________________________

Employer ______________________________________________________________________

Spouse’s Name ______________________ Phone ____________________________________

Circle those numbers where I may call you:                     Home    Mobile     Work    Spouse

Circle numbers where I might leave a message for you:  Home     Mobile     Work    Spouse

May I mail appropriately labeled correspondence to your home address?       Yes       No

Alternate Address (if applicable): __________________________________________________

Referred by: _________________________________________

In case of emergency, contact:

Name: ____________________________________ Phone: _____________________________

What is the primary reason you are seeking a consultation? _____________________________

______________________________________________________________________________

When did issues in the marriage first appear? ________________________________________

What, if anything, makes these issues worse? _______________________________________

______________________________________________________________________________

What, if anything, makes these issues better? ______________________________________

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Have family members, friends or coworkers urged you to seek treatment?  If so, why? ________

_____________________________________________________________________________

Please list other psychiatrists you have seen, previous diagnoses, and dates of treatment: _______

______________________________________________________________________________

_____________________________________________________________________________

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Please list all medications you are currently taking: ____________________________________

______________________________________________________________________________

Please list all substances used or abused, now or in the past, and approximate dates: __________

_____________________________________________________________________________

Method of contraception:  ________________________________________________________

Please list all drug allergies: _______________________________________________________

Please list all medical problems: ___________________________________________________

_____________________________________________________________________________

Please list all previous surgeries: __________________________________________________

Please list all previous psychiatric hospitalizations: _____________________________________

______________________________________________________________________________

Please list all medical and psychiatric conditions present in family members (please include alcohol and drug abuse problems):

Parents: _______________________________________________________________________

______________________________________________________________________________

Siblings: ______________________________________________________________________

______________________________________________________________________________

Grandparents: __________________________________________________________________

______________________________________________________________________________

Aunts and Uncles: ______________________________________________________________

______________________________________________________________________________

Children: _____________________________________________________________________

______________________________________________________________________________

What is your level of education? ___________________________________________________

I certify this information is true to the best of my knowledge.  I will notify you of any change in my health status, or any of the above information.

I understand 24 hour cancellation notice is required to avoid being charged for a scheduled appointment.

I understand that, unless previous arrangements have been made, I am responsible for filing my own health insurance.

 

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(Signature)                                                                         (Date)