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Relationship Therapy Intake Form
Malwina Andruczyk, LCSW, SIFI
When your intake form is received, Malwina will contact you to set up a 15 minute phone screening and you will be on your way to your first session.
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* Indicates required question
Please provide your full name
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
What gender pronouns do you use?
*
Such as they/them/theirs, she/her/hers, he/him/his, or whatever feels most comfortable and true to you
Your answer
How do describe your racial and ethnic identities?
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
Address
*
Your answer
What are some good times to reach you for a follow up call?
*
Your answer
Relationship style (poly, open, non-monogamous, kink dynamics, only if comfortable sharing):
Your answer
Current partner(s):
Your answer
Does your relationship(s) bring you happiness and/or fulfillment?
Your answer
What is your sexual relationship like with your partner(s)?
Your answer
Is there any area of your sexuality you wish you could explore more?
Your answer
How would you describe your communication style? Your partner’s communication style?
Your answer
What brings you to counseling at this time?
*
Is there a something specific, such as a particular event? Be as detailed as you can.
Your answer
What are your goals for counseling?
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Your answer
What would you like your relationship to look like in a year? Two years? Five years?
Your answer
Have you seen a mental health professional before?
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Yes
No
If you have been in treatment before, when was your last mental health session?
Your answer
What do you consider your greatest strength?
Your answer
Creative projects/practices (art, music, writing, movement etc.):
Your answer
Spiritual beliefs:
Your answer
Self care practices:
Your answer
Are you engaged with any other healers/doctors/guidance?:
Your answer
If taking prescription medication for mental health--please list here.
Your answer
Relationship to drugs & alcohol & if you are currently using either:
*
Your answer
Have you ever been hospitalized for a psychiatric issue? If so--when was your last date of hospitalization?
*
Your answer
Describe your current living situation. Do you live alone, with others, with family, etc?
*
Your answer
Please check any of the following you have experienced in the last 6 months.
*
Trouble concentrating
Decreased appetite
Increased appetite
Joy
Difficulty sleeping
Low motivation
Sense of connection to something larger than yourself
Self isolation (avoiding friends/family)
Hopefulness
Fatigue/low energy
Relaxed state of mind
Changes in your self esteem
Irritability/anger
Depressed mood
Anxiety
Hopelessness
Other:
Required
Anything else you would like me to know?
*
Your answer
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