Couples Intake Form Step 1 of 3 - Client Profile 33% A. Client ProfileFull Legal Name First Middle Last Suffix Preferred Name First Last Date of BirthSocial Security Number: (secured)Best Contact NumberAlt Contact NumberOK to Leave a Voice Mail?YesNoEmail Address Street Address City County State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Partner's NameChildren? Check if applicable Children's Name and Date of Birth Child's Name Child's Date of Birth Edit Delete There are no Children. Add Child Maximum number of children reached. In Case of EmergencyEmergency Contact Name Last Emergency Contact PhoneRelationship to YouHow did you hear about The Center for Family Resolution?If referred, by whom?May I have permission to thank this person for the referral? Yes No B. General QuestionnaireWhat 3-5 words best describe your partner:Briefly describe what most attracts you to your partner?Why are you seeking marriage counseling?Describe how you met your partner:What do you most appreciate about your relationship?List your strengths: Who are your best supporters?How do you take care of yourself?Briefly describe your general health, including any medications you are currently taking:Are you currently experiencing anxiety, depression or chronic pain?What is your primary source of stress relief?What are your favorite recreational activities?Select the number that best represents your level of job satisfaction:low 012345678910 highDescribe your work-life including job title, primary responsibilities and work hours:Describe your relationships with your family:Describe what you learned about relationships growing up:Describe any traumatic events that impact your relationship:Select the number that best represents your current level of self-esteem;low 012345678910 highBriefly describe your habits for sleeping / eating / exercise:Briefly describe your habits for alcohol / recreational drug use:What additional background information can you provide that you think would be most helpful to me when coaching / counseling with you? C. Family Health HistoryIn the section below, identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you in the space provided ( father, grandmother, uncle, etc. )Alcohol/Substance Abuse Yes No Family member relationship: Bi Polar Yes No Family member relationship: Depression Yes No Family member relationship: Domestic Violence Yes No Family member relationship: Eating Disorders Yes No Family member relationship: Anxiety Yes No Family member relationship: Obsessive Compulsive Behavior Yes No Family member relationship: Schizophrenia Yes No Family member relationship: Suicide Attempts Yes No Family member relationship: Have you previously met with a coach / counselor? This iframe contains the logic required to handle Ajax powered Gravity Forms.