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Couples/Family Information Form
Nicole Pray
2023-12-11T09:06:13+12:00
Couples / Family Information Form
Which team member are you here to see?
(Required)
Please select
Dr Nicole Pray
Who referred you?
Date
DD slash MM slash YYYY
Marital Status
Please Select
Married
Separated
Divorced
Widowed
Living Together
Other
Married how long?
If selected 'Other' for Marital Status, please clarify:
Children
Name
Date of Birth/Age
Step/Bio/Adopted
Add
Remove
Click on the plus + symbol to add multiple children
Client 1
Name
(Required)
First
Last
Previously Married?
Yes
No
Date of Birth
DD slash MM slash YYYY
Age
Ethnicity
Address
Street Address
City
State / Province / Region
Postal Code
Email Address
(Required)
Home Phone
Mobile Phone
Employer
Work Phone
Please select where I can call you and leave messages
At Home
At Work
On your mobile
Medical History
Are you currently experiencing physical problems or medical problems (e.g. headaches, body aches, stomach problems)?
Yes
No
Please list any learning disabilities:
If yes, please explain:
Medication Information
Medication(s)
Dosage
Add
Remove
Click on the plus + symbol to add multiple medications and dosages
Counseling and Psychiatric History
Have you had previous counselling?
Yes
No
If yes, when
If yes, for what reason?
Name and location of counselor:
For how long?
Have you ever been diagnosed with or treated for any type of mental illness?
Yes
No
If yes, what?
Has anyone in your family been diagnosed with or treated for any type of mental illness?
Yes
No
If yes, what?
Reasons for seeking help
What do you hope you will gain from counseling?
What concerns have brought you to counseling today?
Emergency Contact (Next of kin - other than spouse)
Name
Relationship
Home Phone
Work Phone
Address
Email
Client 2
Name
(Required)
First
Last
Previously Married?
Yes
No
Date of Birth
DD slash MM slash YYYY
Age
Ethnicity
Address (If different from the address above)
Street Address
City
State / Province / Region
Postal Code
Email
(Required)
Home Phone
Mobile Phone
Employer
Work Phone
Please select where I can call you and leave messages
At Home
At Work
On your mobile
Medical History
Are you currently experiencing physical problems or medical problems (e.g. headaches, body aches, stomach problems)?
Yes
No
Please list any learning disabilities:
If yes, please explain:
Counseling and Psychiatric History
Have you had previous counselling?
Yes
No
If yes, when
If yes, for what reason?
Name and location of counselor:
For how long?
Have you ever been diagnosed with or treated for any type of mental illness?
Yes
No
If yes, what?
Has anyone in your family been diagnosed with or treated for any type of mental illness?
Yes
No
If yes, what?
Medication Information
Medication(s)
Dosage
Add
Remove
Click on the plus + symbol to add multiple medications and dosages
Reasons for seeking help
What do you hope you will gain from counseling?
What concerns have brought you to counseling today?
Emergency Contact (Next of kin - other than spouse)
Name
Relationship
Home Phone
Work Phone
Address
Email
Would you like a copy of this form emailed to you?
Yes
Which email address/es should we send the form to?
