← Return to Forms & Fees

Laura Young, LCSW Counseling Services, P.C.
315 W. 57th St  Suite 310
New York, NY 10019
Email: Info@LLYoung.com
Tel: 212.581.9466

Client Intake Form
for Couples, Families & IMAGO

To avoid form errors, complete in one sitting
while you are connected to the web.

Please fill out as completely as possible.
At the end of the form, press send.

Basic Info
Name *
Name
Address *
Address
Mobile/Cell Phone *
Mobile/Cell Phone
Work Phone
Work Phone
Home Phone
Home Phone
Date of Birth *
Date of Birth
Family & Partnerships
1=Poor, 10=Excellent
If yes, how many? Please list their ages.
Do you have any brothers? How many?
Do you have any sisters? How many?
(eg: Oldest, Middle, Youngest etc.)
Education & Work
1= Most Important 5=Least Important
1= Most Important 5=Least Important
1= Most Important 5=Least Important
1= Most Important 5=Least Important
1= Most Important 5=Least Important
1= tremendous dis-satisfaction/annoyance 10=great enjoyment/satisfaction with the school I attended
1= tremendous dis-satisfaction/annoyance 10=great enjoyment/satisfaction with the school I attended
1= tremendous dis-satisfaction/annoyance 10=great enjoyment/satisfaction with the school I attended
1= tremendous dis-satisfaction/annoyance 10=great enjoyment/satisfaction with the school I attended
1= tremendous dis-satisfaction/annoyance 10=great enjoyment/satisfaction with the school I attended
1= tremendous dis-satisfaction/annoyance 10=great enjoyment/satisfaction with the school I attended
Is there anything stressful about your current work?
General Health & Mental Health Information
Have you previously received any type of mental health services? *
Check all that apply. (eg: psychotherapy, psychiatric services, etc)
If you are currently taking any prescription medications, please list each medication & the reason.
How would you rate your current physical health? *
How would you rate your current sleeping habits? *
Please describe your faith or belief.
Family Mental Health History
Family History *
In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you in the space provided (father, grandmother, uncle, etc) Check all that apply
Please indicate the family member's health challenge & relationship to you in the space provided (father, grandmother, uncle, etc)
If any area checked "Yes," please provide any details that are important or useful for me to know
Indicate the kind of therapy you are requesting *
Check all that apply
Client Relational Inventory
Environmental Stressors:
Please describe significant negative or positive events or changes which have occurred in the past five years. (Please include family of origin, immediate family - anyone or anything that has impacted you) Reply N/A (Not applicable) as needed.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Satisfaction Within the Relationship
Please select the option that best describes the degree of overall satisfaction in your family, all things considered. The list details some of the specific areas that, taken together, make up general satisfaction within the relationship. Please select that which best represents your happiness with the way you and your partner/family usually interact in each area:
Our daily social interaction with each other:
Our affectionate interaction:
Our sexual interaction:
Our trust in each other:
Our communication:
The way we divide chores:
The way we make decisions:
The way we manage conflict:
Our management of children (if any):
Amount of time spent apart:
Amount of time spent together:
Quality of time together:
The way we support each other in crisis:
The way we share financial decision making:
Looking back over this list one more time, please self-reflect and suggest some ways in which a change in your own behavior might improve your satisfaction in any of the areas related to 'Very Unsatisfied' or 'A little Unsatisfied'
Goals of Counseling
Which one of the following statements comes closest to expressing what you hope to gain from this counseling experience? *
General Commitment to the Relationship
These questions address the level of your general commitment to your relationship. Commitment varies over time—at some times it is very strong, at other times weaker—and its level may affect your partner’s or your family’s willingness to try to improve the relationship. The following questions are concerned with your commitment level and some of its components. Select the response closest to your current feelings. Please substitute the word “family” for “partner” when applicable
Please list at least three different scheduling possibilities

Before you press send, make sure all required sections
are complete & you are connected to the web.