RelationshipIntake - Tess Counselling

First Name*

Middle Name*

Last Name*

Birth Date*

Email*

Address*

Home Address Suburb State Postcode

Mobile*

Home Phone*

Work Phone*

Please provide your partner's name.*

What are the relationship issues that have brought you to counselling?*

How long have you known each other?*

How long have you been in this relationship?*

If you are married, how long have you been married?

Please provide any further details you feel are relevant to these questions..

DO you have children either together or as individuals?*

Yes
No

Please provide any names and ages of your children.

Child's Name	Child's Age

What changes would you like to occur, as a result of this counselling?*

Are you presently engaging in counselling elsewhere?*

Yes
No

If so, with whom?

For how many sessions?

What issues are you addressing with them?

Have you previously engaged in counselling?*

Yes
No

If so with whom?

Approximate number of sessions / length of time?

How long ago?

What was that/those counselling experiences like for you?

Please list any medications you take for mental health reasons:*

What made you choose this counselling practice?*

CONFIDENTIALITY:

Any information shared during counselling will be respected and kept in confidence. However many settings place additional specific limitations on confidentiality - sincere attempts will be made to discuss such situations with you before any relevant reporting is undertaken. Such reporting is done only in an attempt to ensure the safety and well being of either yourself and/or others.

If you have any concerns regarding your safety (physically, emotionally or psychologically), when engaging in your initial relationship therapy, please contact Tess.

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