Intake Form

Full Name

Relationship Status

Single Married Divorced Seperated

Cell Phone Number

Work Phone Number

E-mail

Name Of Spouse

Date Of Birth

Spouse Home Phone

Spouse Work Phone

Whom May We Thank for Referring You?

Address

Presenting Problem

Significant Medical History

Are You Currently Taking Any Medication?

If Yes, Name of Medication

Dosage

Prescribed By

Reason

Do You Have Major Medical Insurance?

Yes No

Insurance ID/Policy Number

Additional Members of Your Household 1 Name

Relationship

AGE

Any Additional Information

Your Marriage
Counselor