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New Client Form

Please fill out the following information so that we can match you with the most appropriate therapist. This information is used for Client Care purposes only and is not shared with anyone outside of Council for Relationships. Fields in RED are required.

Email Address:
Client Name:
Age: Occupation:
   
Partner/Child's Name:
Age: Occupation:
    
Type of Therapy:
Relationship Status: Length:
   
Where did you learn of CFR?
Is Your Partner Aware You Are Contacting CFR?
Is it OK for a representative from CFR to leave a 
message at the number(s) you provide?
   
Street Address:
City, State, Zip:
Preferred Telephone:
Alternate Telephone:
   
Preferred Location:
Availability:
Check all that apply		 Morning     Afternoon    Evening
Annual Household Income:
     
Children:  
Client's   Partner's   Together  
Boys Boys Boys
Girls Girls Girls
   
Areas of Concern:  
Are there any issues relating to alcohol or substance use?
If yes, please explain.
 
Is there any history of physical conflicts? 
If yes, what is the frequency and date of last incident? 
Was there police involvement? 
 
Are you currently taking any medications for mood or anxiety? If yes, please identify medications. 
 
Are you currently involved in any legal issues relating to therapy sought? If yes, please explain.
 
Have you ever been in therapy before? 
              If yes, was it with Council for Relationships? 
Are you a Veteran of the Iraq/Afghanistan War?  
What are the key areas you would like to address in therapy?
Would you like to sign up to receive the Relationship Tip of the Week by email?  

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