Intake Form – Christina Bronte Wellness Intake Form - Christina Bronte Personal:Name:* First Last Preferred Pronouns: Type of therapy you are requesting: Couples Individual Family Referred by: Date of Birth:* Age:* Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell Phone:*Voice Mail OK?* Yes No Text Message OK?* Yes No Email:* Employment / Education:Your current employer/business or school:* Your occupation / title:* How long? Work Phone:Voice Mail OK?* Yes No Text Message OK?* Yes No Family Information:Do you have children?* Yes No If yes, please list names and ages below:Select all that apply to the children in your family: Biological Adopted Blended Living with you Infertility Your culture and relationship status:Select all that apply and include numbers of years in the comments section:* Single Engaged Widowed Committed Married Separated Divorced Living With Comments:Are there aspects of your cultural, racial, religious, sexual identity, values and/or experiences that you feel would be helpful for me to know? If so, please describe:Previous Therapy:Have you been in therapy before?* Yes No If yes, with whom? For how long? Was it a positive experience? When did you stop? Medical Information:Physician's Name:* First Last Physician's Phone:List any medical conditions you may have:List all prescription medications you are taking:List Over The Counter and other products (i.e. Supplements):Has there ever been a time where you thought about or attempted to hurt yourself?Person to reach in the event of an emergency:Name:* First Last Phone:*Relationship:* Leisure / Self Care:How do you use your free time?*When you are on the internet, where do you spend your time?*Goals and Objectives:What are the things you like most about your life and your relationship?*What are current issues you'd like to address in therapy?*What are your goals for the outcome of our work together?*Your expectation(s) of me as your therapist:*Please complete: I will be finished with therapy and consider it successful when*Consent* I agree these statements are true.
