Individuals Intake Form

Help me get to know you

Complete the required fields and share your responses with me

The Information You Share Will Be Confidential

Name *

Email address *

Phone Number *

Person to notify in case of emergency *

Relationship Status *

Domestic Violence (Physical Abuse) *

Are you currently experiencing feelings of sadness, anxiety, or stress? *

Have you been having thoughts of harming yourself or others? *

Have you ever participated in Counseling (Therapy) before? *

What brings you to counseling at this time? *

What would you like to achieve through our work together? *

What do you imagine it's like to be in relationship with you? *

What I'm doing that's keeping me from having the relationship I long for. *

What is one thing I can do differently to create the relationship I want? *

Who normally needs to change most in your relationship? *

What are your "blind spots" that have been pointed out to you? *

Are you currently taking any medication for mental health? *

Have you received a diagnosis of Bipolar Disorder, Borderline or Narcissistic Personality Disorder? *

Can you tell me about your support system? *

Do you use alcohol or drugs? If so, how often and how much? *

Legal History *

Litigation *

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One JourneyTwo Hearts