Intake Family History

For each item below you may indicate a name or initials, current age (or year of birth and death), level of education, type of work, significant health issues. For example "JD, 51, college, manager, good health."

Your Name

Your Email

Your counsellor's email

Your Children - 1 per line

You and your siblings - 1 per line

Your Mother and her siblings (optional)

Your Father and his siblings

Your Grandparents

Your partner and siblings - 1 per line

Your partner's mother and siblings (optional)

Your partner's father and siblings

Your partner's grandparents

Other information (optional)

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For each item below you may indicate a name or initials and a short description of the relationship and the frequency of contact. For example: JD, close, regular phone calls and visits; AB, distance, no contact; JF, conflictual, several times a year.

Your Name

Your Email

Your counsellor's email

Relationship with mother

Relationship with father

Relationship with siblings

Relationship with grandparents

Relationship with partner

Relationship with children

Relationship with inlaws

Other information (optional)

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For each item below you may indicate a name or initials and a short description of the event and its significance. For example: JD, birth, first child; Our family, first house, financial challenge: JD, college, struggled; MA, cancer, recovered;

Your Name

Your Email

Your counsellor's email

Events with mother

Events with father

Events with siblings

Events with grandparents

Events with partner

Events with children

Events with inlaws

Other events (optional)

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