Deborah L. Galindo, Psy.D th St. SE, Ste 420 Salem, OR Phone: Fax: (503) or (503)
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1 Deborah L. Galindo, Psy.D th St. SE, Ste 420 Salem, OR Phone: Fax: (503) or (503) COUPLES THERAPY INTAKE QUESTIONNAIRE (EACH PARTNER NEEDS TO COMPLETE THIS FORM SEPARATELY) NAME: What brought you into therapy at this time (i.e., what events or conversations prompted the action)? _ What do you wish to change or accomplish as a result of therapy? (Describe 3 improvements you hope to observe in your relationship by the end of treatment). Provide a brief timeline of your relationship (including important dates or events) and explain in a sentence or two what makes this relationship is meaningful or special to you (i.e., what do you treasure or appreciate most about your history together?). _ What attempts have you made to address concerns with your partner? How does your partner respond & would have you observed any of success at all with these attempts or strategies? Have you been in therapy before? If yes, please note the when, name of clinician/agency, primary issues addressed, & indicate whether it was helpful.
2 Reflecting on the last 6 months, please circle all that apply: Frequently sad or depressed Feeling restless or keyed up Overwhelming worries Difficulty falling asleep or staying asleep Unable to concentrate Irritable and/or short temper Significant change in weight Low energy level/fatigue Feeling excessive guilt or shame Unable to relax Lack of appetite/increased appetite Loss of interest in activities/hobbies Feeling hopeless Feeling worthless Difficulty motivating Withdrawn/isolating self Cry easily/often Difficulty making a decision Difficulty finishing tasks Thoughts to hurt self Attempts to harm yourself Thoughts to hurt others Feeling ill/sick Threats to hurt others Restless unsatisfying sleep Muscle tension Mood Swings Decreased need for sleep (only need 3-4 hrs) Feel more talkative than usual Excessive spending/shopping Excessive gambling Easily distracted by unimportant things Take too many risks Troubling thoughts about the past Nightmares Exaggerated startle response Too neat and orderly Repeating certain behaviors over and over Easily upset or angered Feeling different from most people Shy around others Increasingly forgetful Strong fears Difficulty with work or school Stomach aches/vomiting Use of painkillers & analgesics Addiction/Compulsion Behavior (pornography, video games, internet, etc)
3 MEDICAL HISTORY Are you currently being treated for any medical problems? Are you currently taking any medications? List medications: Dosage Type For (i.e. depression) Prescribed by Are you currently taking over the counter medications, herbs or supplements? Are you presently in good health? Do you engage in physical activity? If yes, what activity? How often? Do you smoke cigarettes (cigars, chew)? # per day How much alcohol do you drink? # per day # per week Do you drink caffeinated beverages? If yes, how many per day? Do you use illicit drugs? If yes, how often and what drugs do you use? Have you ever tried to cut down or stop using alcohol or drugs? Has anyone ever asked you to cut down on your drinking? Have you ever been hospitalized for any emotional/ mental health condition? Have you experienced or witnessed a traumatic event? (parental violence, domestic violence, community violence, natural disaster, injury or death to a loved one, etc) Do you have a history of domestic violence? Do you have a history of verbal, emotional or physical abuse?
4 Do you have a history of sexual abuse or sexual assault? If you answered to any of the questions in this box, please provide the general details below (including date/duration of events) SUPPORT SYSTEMS Do you have one or two friends that you consider close and feel you can depend on? Do have a religion or spiritual practice that you experience as supportive? Do you belong to any social groups or participate in hobbies with people that you enjoy? Is there a family member that you trust and can go to in times of emotional need? Are there other people or aspects of your life that you consider supportive? FAMILY HISTORY Have you or anyone in your family, experienced any of the following? If yes, please note their relationship to you. Please include extended family such as grandparents, uncles/aunts, siblings, and so on. Has anyone experienced: Anxiety Depression Bipolar disorder Family Member(s)
5 Learning disorders (ADHD, dyslexia, etc). Illicit drug use Alcohol abuse Schizophrenia Anger Eating Disorder Phobias Hospitalization for Mental Health Condition Attempted or completed suicide Marriage or Partnership History (fill in blank where applicable): Length of relationship with Partner: Length of Engagement: Number of Previous Relationships that Lasted More Than 6 Months: Date of Marriage: Number of Breakups/Separations: Length of Separations/Breakups If this is not your first marriage, please list dates of previous marriages below & primary reasons for divorce:
6 Intimate Relationship Issue Checklist Seriousness of Issue Issue t at all Somewhat Serious Extremely serious Communication Affection Physical Attraction Sex Religion/Spirituality Money/Finances In-laws (Partner s Family) Friends Alcohol/Drug Use Children/Parenting Roles Romance Recreation/Companionship Career Choice (work schedules) Stress Health Problems Legal Issues Domestic Violence Emotional/Verbal Abuse Commitment/Infidelity/Trust List 3 of your strengths & describe how each strength impacts the life of your partner: List 3 of your partner s strengths & describe how each strength impacts your life:
7 Do you find it difficult to assert your feeling or be open & honest with your partner? If, please attempt to explain: Do you have children? If yes, please complete box below: Name Date of Birth Age Where does child reside? Do any of your children have special needs? Does anyone else currently live in the home? If yes, what is their relationship to you? Please note any other issues that you think or feel would be good for your psychologist to know: ~ Thank you ~
8 COUPLES THERAPY INTAKE QUESTIONNAIRE (EACH PARTNER NEEDS TO COMPLETE THIS FORM SEPARATELY) NAME: What brought you into therapy at this time (i.e., what events or conversations prompted the action)? _ What do you wish to change or accomplish as a result of therapy? (Describe 3 improvements you hope to observe in your relationship by the end of treatment). Provide a brief timeline of your relationship (including important dates or events) and explain in a sentence or two what makes this relationship is meaningful or special to you (i.e., what do you treasure or appreciate most about your history together?). _ What attempts have you made to address concerns with your partner? How does your partner respond & would have you observed any of success at all with these attempts or strategies? Have you been in therapy before? If yes, please note the when, name of clinician/agency, primary issues addressed, & indicate whether it was helpful.
9 Reflecting on the last 6 months, please circle all that apply: Frequently sad or depressed Feeling restless or keyed up Overwhelming worries Difficulty falling asleep or staying asleep Unable to concentrate Irritable and/or short temper Significant change in weight Low energy level/fatigue Feeling excessive guilt or shame Unable to relax Lack of appetite/increased appetite Loss of interest in activities/hobbies Feeling hopeless Feeling worthless Difficulty motivating Withdrawn/isolating self Cry easily/often Difficulty making a decision Difficulty finishing tasks Thoughts to hurt self Attempts to harm yourself Thoughts to hurt others Feeling ill/sick Threats to hurt others Restless unsatisfying sleep Muscle tension Mood Swings Decreased need for sleep (only need 3-4 hrs) Feel more talkative than usual Excessive spending/shopping Excessive gambling Easily distracted by unimportant things Take too many risks Troubling thoughts about the past Nightmares Exaggerated startle response Too neat and orderly Repeating certain behaviors over and over Easily upset or angered Feeling different from most people Shy around others Increasingly forgetful Strong fears Difficulty with work or school Stomach aches/vomiting Use of painkillers & analgesics Addiction/Compulsion Behavior (pornography, video games, internet, etc)
10 MEDICAL HISTORY Are you currently being treated for any medical problems? Are you currently taking any medications? List medications: Dosage Type For (i.e. depression) Prescribed by Are you currently taking over the counter medications, herbs or supplements? Are you presently in good health? Do you engage in physical activity? If yes, what activity? How often? Do you smoke cigarettes (cigars, chew)? # per day How much alcohol do you drink? # per day # per week Do you drink caffeinated beverages? If yes, how many per day? Do you use illicit drugs? If yes, how often and what drugs do you use? Have you ever tried to cut down or stop using alcohol or drugs? Has anyone ever asked you to cut down on your drinking? Have you ever been hospitalized for any emotional/ mental health condition? Have you experienced or witnessed a traumatic event? (parental violence, domestic violence, community violence, natural disaster, injury or death to a loved one, etc) Do you have a history of domestic violence? Do you have a history of verbal, emotional or physical abuse?
11 Do you have a history of sexual abuse or sexual assault? If you answered to any of the questions in this box, please provide the general details below (including date/duration of events) SUPPORT SYSTEMS Do you have one or two friends that you consider close and feel you can depend on? Do have a religion or spiritual practice that you experience as supportive? Do you belong to any social groups or participate in hobbies with people that you enjoy? Is there a family member that you trust and can go to in times of emotional need? Are there other people or aspects of your life that you consider supportive? FAMILY HISTORY Have you or anyone in your family, experienced any of the following? If yes, please note their relationship to you. Please include extended family such as grandparents, uncles/aunts, siblings, and so on. Has anyone experienced: Anxiety Depression Bipolar disorder Family Member(s)
12 Learning disorders (ADHD, dyslexia, etc). Illicit drug use Alcohol abuse Schizophrenia Anger Eating Disorder Phobias Hospitalization for Mental Health Condition Attempted or completed suicide Marriage or Partnership History (fill in blank where applicable): Length of relationship with Partner: Length of Engagement: Number of Previous Relationships that Lasted More Than 6 Months: Date of Marriage: Number of Breakups/Separations: Length of Separations/Breakups If this is not your first marriage, please list dates of previous marriages below & primary reasons for divorce:
13 Intimate Relationship Issue Checklist Seriousness of Issue Issue t at all Somewhat Serious Extremely serious Communication Affection Physical Attraction Sex Religion/Spirituality Money/Finances In-laws (Partner s Family) Friends Alcohol/Drug Use Children/Parenting Roles Romance Recreation/Companionship Career Choice (work schedules) Stress Health Problems Legal Issues Domestic Violence Emotional/Verbal Abuse Commitment/Infidelity/Trust List 3 of your strengths & describe how each strength impacts the life of your partner: List 3 of your partner s strengths & describe how each strength impacts your life:
14 Do you find it difficult to assert your feeling or be open & honest with your partner? If, please attempt to explain: Do you have children? If yes, please complete box below: Name Date of Birth Age Where does child reside? Do any of your children have special needs? Does anyone else currently live in the home? If yes, what is their relationship to you? Please note any other issues that you think or feel would be good for your psychologist to know: ~ Thank you ~
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