Family Intake Form

*If you choose to complete this form as a family, please write all members’ names in the “first name” box.

Date Completed

YYYY

Name

First Name

Last Name

What are your goals for family counseling?

What does your family do together that you enjoy?

If you could change one thing about your family, what would it be?

Do you feel physically safe in your family?

If not, please explain further.

Do you feel emotionally safe in your family?

If not, please explain further.

Rate this statement: I am willing to participate in family therapy and am excited to see changes in my relationships.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree