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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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* Anger obligatorisk fråga
Please provide your full name
*
Ditt svar
Date of birth
*
MM
/
DD
/
ÅÅÅÅ
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
Ditt svar
How do describe your racial and ethnic identities?
Ditt svar
Email Address
*
Ditt svar
Phone Number
*
Ditt svar
Address
*
Ditt svar
What are some good times to reach you for a follow up call?
*
Ditt svar
Relationship style (poly, open, non-monogamous, kink dynamics, only if comfortable sharing):
Ditt svar
Current partner(s):
Ditt svar
Does your relationship(s) bring you happiness and/or fulfillment?
Ditt svar
What is your sexual relationship like with your partner(s)?
Ditt svar
Is there any area of your sexuality you wish you could explore more?
Ditt svar
How would you describe your communication style? Your partner’s communication style?
Ditt svar
What brings you to counseling at this time?
*
Is there a something specific, such as a particular event? Be as detailed as you can.
Ditt svar
What are your goals for counseling?
*
Ditt svar
What would you like your relationship to look like in a year? Two years? Five years?
Ditt svar
Have you seen a mental health professional before?
*
Yes
No
If you have been in treatment before, when was your last mental health session?
Ditt svar
What do you consider your greatest strength?
Ditt svar
Creative projects/practices (art, music, writing, movement etc.):
Ditt svar
Spiritual beliefs:
Ditt svar
Self care practices:
Ditt svar
Are you engaged with any other healers/doctors/guidance?:
Ditt svar
If taking prescription medication for mental health--please list here.
Ditt svar
Relationship to drugs & alcohol & if you are currently using either:
*
Ditt svar
Have you ever been hospitalized for a psychiatric issue? If so--when was your last date of hospitalization?
*
Ditt svar
Describe your current living situation. Do you live alone, with others, with family, etc?
*
Ditt svar
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
Övrigt:
Obligatorisk
Anything else you would like me to know?
*
Ditt svar
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