Client intake questionnaire - Family Counseling 2026

1. Click ‘Get Form’ to open the client intake questionnaire in our editor.
2. Begin by entering the date and your name at the top of the form. Select your gender and provide your Social Security Number and Date of Birth.
3. Fill in your home address, city, state, and zip code. Provide a contact phone number and indicate if you would like messages left or texts sent for appointment reminders.
4. Complete the sections regarding your religious beliefs and current employment status. Include details about your emergency contact person.
5. Indicate your marital status and relationship satisfaction. If applicable, provide information about prior marriages.
6. In the 'Responsible Party Information' section, fill out details of the person responsible for any fees incurred during counseling.
7. Provide insurance information, including policy holder details and whether deductibles have been met.
8. Complete health history questions, including current medications, past trauma experiences, and family history.
9. Check any specific problem areas that are currently troubling you from the provided list.
10. Finally, review all entered information for accuracy before signing at the bottom of the form to consent to treatment.

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