GrIEF AND BEREAVEMENT COUNSELING Intake Form Section 1: Personal Details Name Date Of Birth MaleFemale Email Phone Number Address Occupation Marital Status Length of Marriage Spouse’s Name Spouse’s Date of Birth Spouse’s Occupation Section 2: Background Information Please describe the current issues or challenges in your marriage that have led you to seek counseling at this time. How long have these issues been present in your marriage? Have you sought counseling or therapy for your marriage in the past? If yes, please provide details. How would you describe the overall communication and emotional dynamics in your marriage? Are there any significant life events or stressors that have impacted your marriage recently (e.g., health issues, financial challenges, family dynamics)? Section 3: Individual history Please provide a brief overview of your personal background, including family dynamics, upbringing, and significant life experiences. How do you currently cope with stress and challenges in your life? Are there any personal concerns or issues that you believe may be contributing to the current challenges in your marriage? Section 4: Relationship History How did you and your spouse meet and what initially attracted you to each other? What have been the strengths of your marriage over the years? What are the main areas of conflict or disagreement in your marriage? How have you and your spouse typically resolved conflicts in the past? Are there any patterns or recurring themes in your conflicts with your spouse? Expectations and Goals What are your expectations for marriage counseling? What do you hope to achieve through this process? What are your personal and relational goals for the future of your marriage? Additional Information Are there any other factors or information that you believe would be important for the counselor to know before beginning therapy?
