For more information:
603.380.6704 / Fax 603.764.7412
[email protected]

1245 Washington Road
Rye, New Hampshire 03870

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For more information:
603.380.6704 / Fax 603.764.7412
[email protected]

1245 Washington Road
Rye, New Hampshire 03870

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November 9, 2023by Lee Germeroth

COUPLE – BACKGROUND & HISTORY

To be completed by both individuals

"*" indicates required fields

Who is your provider?*

Today’s date*

MM slash DD slash YYYY

Client Legal Name*

First Middle Last

Client Preferred Name*

First Middle Last

Date of Birth*

Month

Day

Year

Street Address*

Street Address Address Line 2 City State ZIP Code

Preferred Email Address*

Would you like to subscribe to our newsletter?*

Yes, keep me up to date with latest news and updates.

Client's Preferred Phone*

Phone Type*

Cell

Home

Work

Gender Identity*

Sex Assigned at Birth*

Occupation*

Employer or School (if student)*

Marital status*

Spouse/Partner (if applicable) and Occupation*

Other family members and ages*

(please note whether living in or outside of the home)

How did you learn about this practice*

Have you sought out individual, family, or couples counseling prior?*

Yes

No

Who?*

When?*

What is the main area of concern that led you to couples/family counseling now?*

How long have you and your partner been together? In what form? (ex: dating, engaged, married, etc).*

Does either partner partake in any form of substances?*

Who?*

What?*

How often?*

Has either partner ever resorted to violence or injuring the other?*

Yes

No

If yes, describe the frequency and catalysts?*

What are some examples of good qualities in your relationship?*

What are some examples of negative qualities in your relationship?*

What is your biggest goal for couples counseling?*

Prior Mental Health Care

First Mental Health Care

When?*

Where?*

Diagnosis (if applicable)?*

Most Recent Care

When?*

Where?*

Diagnosis (if applicable)?*

FINANCIALLY RESPONSIBLE PARTY

An adult client or an adult guardian who has assumed the cost of treatment. Payment is expected at the time of service.

Name*

First Last

Relationship*

Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact*

Relationship*

Phone*

PRESENTING PROBLEM(S)/ SYMPTOMS: (type and duration). How do these impact your functioning (at home, work, school, interpersonally)?*

HISTORY OF DIFFICULTY AND PRECIPITATING FACTORS*

PSYCHIATRIC TREATMENT HISTORY, MEDICATIONS*

If none reported, check here*

None reported

PERTINENT BACKGROUND*

(# of siblings, marriages/significant relationships, children, impacting events, e.g. moves, developmental changes, sexual/physical/emotional abuse, trauma, divorce.)

MEDICAL HISTORY*

(Current & past medications & dosages, illnesses, etc.)

If none reported, check here*

None reported

SUBSTANCE USE AND ANY SUBSTANCE ABUSE HISTORY*

(Client or Family)

If none reported, check here*

None reported

SOCIAL/SPIRITUAL/INTERPERSONAL SUPPORT SYSTEM OR ACTIVITIES*

If none reported, check here*

None reported

LEGAL ACTIVITY*

(Arrests, violations, warnings, Conditional Discharge, DWIs, probation (past or present), guardianships, durable power of attorney, living wills, JSOs, DCYF involvement, etc.)

If none reported, check here*

None reported

Abuse &/or Neglect*

Yes

No

Delinquency*

Yes

No

If Yes to any of the above, please list contact person*

What are your strengths, or other things you are particularly good at or enjoy doing?*

Medical Information

Present health of client*

Previous medication (not for common illnesses)*

Current medications (include all and who is prescribing them)*

Have you been hospitalized or had surgeries (please describe)*

Last Vision Test Date*

Month

Day

Year

Do You Wear Glasses?*

Yes

No

If Yes, When?*

Month

Day

Year

Last Hearing Test Date*

Month

Day

Year

Do You Use Hearing Aids?*

Yes

No

Any family history of mental health concerns?*

(i.e. Adhd, learning disabilities, depression alcoholism, anxiety) or neurological disorders (i.e. seizures, Tourettes, autism)

Prior Psychological Evaluations/Treatment

Have you been evaluated previously?*

Yes

No

If yes, please indicate where this occurred, when and why the evaluation was conducted.*

Are you currently receiving counseling or therapy services elsewhere?*

Yes

No

If yes, please indicate name of provider and length of time being seen?*

Other care professionals you are currently undergoing treatment with (e.g. other medical professionals such as acupuncturist, chiropractor, medical specialists, etc.)

Physician*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Other

Phone

Address

Street Address Address Line 2 City State ZIP Code

Other

Phone

Address

Street Address Address Line 2 City State ZIP Code

Other

Phone

Address

Street Address Address Line 2 City State ZIP Code

Any other information that you feel is important for me to know?

Email

This field is for validation purposes and should be left unchanged.

Please wait for the confirmation before closing out of the form.

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