Family Therapy Intake

Prepare for the first session by getting to know the family in advance: household members, main concerns, therapy goals, prior treatment and insurance details. Everything the therapist needs before work begins.

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Family name

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Phone number

Email

Name

Nombre

Apellido

Date of birth

Relationship to other family members

Occupation

Briefly describe the main concerns or challenges the family is facing

What specific goals or outcomes would you like to achieve through family therapy?

Has any family member received counseling or therapy before? If yes, please give details

Are there significant medical or health issues in the family the therapist should know about?

Insurance provider

Policy/ID number

Group number

Name

Nombre

Apellido

Relationship to the family

Phone number

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