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CONFIDENTIAL Intake Form
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Estimated completion time: 20-30 minutes

Marital Status
I have already consulted with:
Have you used recreational drugs?
Are you happy with your current job?
Do you come from any religious background?
Check the items that best describe your need to receive counseling
Marriage ( if applicable). This is your?
Have you ever been separated or divorced?
Check if in your marriage you are COMPATIBLE in each of the following areas
As a child you felt closer to your
Have you ever felt rejected by your parents?
Have you ever felt that you left your parents down?
As a child or teen or later on in life, did you ever suffer an injustice, including sexul molestato? What was it and by whom?
Which of these apply to your life. Choose as many as you need.
When in conflict I generally believe I am?
When I am in a conflict I generally:

Thanks for submitting!

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