Individual Intake Form

A. Client Profile

Name of the CFR professional assisting you:(Required)

Amy Armstrong

Wendi Stern

Terri Johnston

Deb Frazier

Bobbie O'Keefe

Full Legal Name(Required)

First Middle Last Suffix

Preferred Name

First Last

Date of Birth(Required)

Social Securtiy Number: (secured)(Required)

Best Contact Number(Required)

Alt Contact Number

OK to Leave a Voice Mail?

Yes

No

Email(Required)

Address(Required)

Street Address Address Line 2 State 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

There are no Children.

Place of Employment

Highest Grade Completed

Military Service

In Case of Emergency

Emergency Contact Name

Emergency Contact Phone

Relationship 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 Questionnaire

Briefly 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?

A. Client Profile

B. General Questionnaire

C. Family Health History

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