Pre-Marriage Intake

E.C.C PRE-MARRIAGE INTAKE INFORMATION
Please PRINT All Information clearly

YOUR NAME: ______________________________________________________ Date: _______________

Address: ______________________________________________________________________

City: _______________________ State: _____________ Zip: _________

Date of Birth: ____/____/____ Age: _____ Sex: (M)____ (F)____

Home Phone #(______)________________ Work Phone #(______)__________________ ext:____

Beeper #(______)__________________ Cell Phone #(______)__________________

How long have you and your fiancé been dating? ___________

Scheduled Wedding Date: ___________________

Name of Priest referring you to our office for Pre-marital counseling:

___________________________________________ Phone #: (_______)_________________

If the therapist needs to speak to the priest - we give permission with these signatures for this to happen. Both signatures are required.

Signature_________________________________________

Printed Name _____________________________________

Signature_________________________________________

Printed Name _____________________________________

How many times have you been married? ____________. How many times has your fiancé been married? __________

Complete information below if previously married. If there have been previous marriages, your therapist may ask you to complete some additional testing at a cost of $50, or come in for additional sessions at $50 per session.

Previous marriages: List month & year

1st marriage: Wedding Date__________

Physically separated__________, Legal separation__________, Divorced__________

2nd marriage: Wedding Date__________

Physically separated__________, Legal separation__________, Divorced__________

3rd marriage: Wedding Date__________

Physically separated__________, Legal separation__________, Divorced__________

Family Members Name				Check if Living At Home
Family Members Name	Age	D.O.B	Relationship	Check if Living At Home

In case of Emergency, the Therapist may Contact: ______________________________________

Phone#: (______)___________________ Relationship to client: ___________________________

Highest level of completed education: ______ Elementary ______ Junior/ Middle School

______ High School ______ Collage ______ Graduate School

Job experience / Skills: Current Employer: ______________________________________

Occupation: _________________________________________

Address: __________________________________________________________________

Job satisfaction: ____ Very High, ____ High, ____ OK, ____ Low, ____ None, ____ Minus

Job Status: (_____) secure, (_____) in jeopardy, (_____) unemployed, (_____) retired,

(_____) disabled, (_____) worker's comp., (_____) social security.

(_____) working more than one job, (_____) other: _______________________

Other kinds of work I am qualified to do: __________________________________________

__________________________________________________________________________

In your own words, state any concerns or problems you may be experiencing as a couple. What has been tried that has helped or tried and made things worse? (Use the back if more space is needed).

_____________________________________________________________________________

General Health: How would you rate your overall health: ⁬ Excellent ⁬ Good
⁬ Average ⁬ Poor

Primary Care Physicians Name: _____________________________________________

Phone # (______)______________ Date of last physical: _________________________

Address: ______________________________________________________________

City: _____________________________ State: _______ Zip: _________________

Have you had any previous counseling? Please list below, continue list on back if more room is needed.

Yes No

Therapist Name: __________________________________ When? ___________________

Phone# (______)______________

Yes No

Therapist Name: __________________________________ When? ___________________

Phone# (______)______________

List ALL Medications being taken at this time: ___________________________________________

________________________________________________________________________________

Medical History (List problems, allergies & dates including surgeries)

________________________________________________________________________________

EPISCOPAL COUNSELING CENTER
POLICY STATEMENT

I understand that I am consenting to pre-marital counseling, have read the policy letter, and that my records will remain at the Episcopal Counseling Center.

I understand that I am responsible for all charges, and that my account may be turned over to a collection agency if full payment is not made.

I also understand that both partners must attend all sessions and that if one is unable to attend, additional time will be scheduled with the therapist at a charge of $50 per hour.

The State of Florida requires that the Episcopal Counseling Center inform you that under the following circumstances, confidentiality will be breached:

When there is cause to suspect a child, adolescent, or elder has been or may be abused.

When there is reasonable cause to believe that you pose risk of imminent harm to yourself.

When there is reasonable cause to believe that you pose risk of imminent harm to another individule.

When there is a valid court order compelling records or witness testimony.

I have read and understand all of the above.

_________________________________ __________________________________
(Client signature) (Client PRINTED Name)

________________________
(Date)