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Family Intake Form

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Family Intake Form

WELL MINDS COUNSELING, PLLC

Tana Carpita, MSW, LICSW

2525 E. Arizona Biltmore Circle, Suite B220

Phoenix, Arizona 85016
(425) 588.9280

Family Information – Please list those who will be present for counseling

Father's Information

Father’s Name *

First

Last

Phone

Email *

Preferred Method of Contact

Phone
Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Age

Date of Birth

Religious Affiliation

Occupation

Employer

Marital Status:

Single
Engaged
Married
Separated
Divorced
Widowed

Mother’s Information

Mother's Name *

First

Last

Phone

Email *

Preferred Method of Contact

Phone
Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Age

DOB

Religious Affiliation

Occupation

Employer

Marital Status:

Single
Engaged
Married
Separated
Divorced
Widowed

Children (List Name and Age):

*if children are partial or step siblings please note next to their name

Health/Mental Health:

Does anyone in the family have significant health diagnoses or a history of such? If so, please specify:

Has anyone in the family been diagnosed with a mental health disorder?

No
Yes

If yes, Please list name, diagnosis and treatment

Has anyone in the family currently or historically been suicidal?

No
Yes

If yes, please specify

Has anyone in the family been hospitalized for mental health?

No
Yes

If yes, please elaborate

Is anyone in the family currently receiving mental health treatment (medication, counseling) from another provider?

No
Yes

If yes, list provider and length of treatment.

Has anyone in the family ever used violence, physical restraint or threats against another member of the family?

No
Yes

If yes, please elaborate:

Reasons for Seeking Family Counseling:

What do you hope to get out of family counseling and how will you know if it has been successful?

List some strengths of your family:

List some weaknesses of your family:

How does your family spend time together?

How does your family deal with conflict?

Do you have family rituals, traditions?

What things do you do together on a daily/weekly basis?

Is there anything else you’d like your therapist to know that has not been asked here?

Contact

Tana Carpita, MSW, LCSW
Well Minds Counseling, PLLC
(425) 588-9280
trcarpita@wellmindscounseling.com

Location

Well Minds Counseling, PLLC
2525 E. Arizona Biltmore
Circle, Suite B220
Phoenix, Arizona 85016

Disclosure

I am an independently licensed clinical social worker, practicing with other clinicians under the name The Biltmore Wellness Collective. Read Full Disclosure

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