Individual Intake Form Step 1 of 3 - Client Profile 33% A. Client ProfileName of the CFR professional assisting you:* Amy Armstrong Wendi Stern Terri Johnston Deb Frazier Bobbie O'Keefe Full Legal Name* First Middle Last Suffix Preferred Name First Last Date of Birth* Social Securtiy Number: (secured)* Best Contact Number*Alt Contact NumberOK to Leave a Voice Mail? Yes No Email* Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Partner Name Co-Parent's Name Children? Check if applicable Children's Name and Date of Birth Child's Name Child's Date of Birth Actions Edit Delete There are no Children. Add Child Maximum number of children reached. Place of Employment Highest Grade Completed Military Service In Case of EmergencyEmergency Contact Name Last Emergency Contact PhoneRelationship to You How 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 QuestionnaireBriefly describe the reason(s) you are seeking coaching/counseling:Give the current roadblocks in the way of the above accomplishment:Tell me what you most appreciate about your current situation:List your family's strengths: 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, panic attacks or phobias?Are you currently experiencing any chronic pain?What is your primary source of stress relief?Briefly 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: Other:Have you previously met with a coach / counselor? Δ
