Family Therapy Intake Form - Cornell & Associates

Name*

First Last

Email*

Interested in virtual or in-person sessions?*

Online therapy (also known as "Teletherapy")
In-person (when we are allowed to do so)
No preference

What can we help you accomplish?*

Have you or family members sought therapy in the past? If so, anything negative or positive you experienced in that treatment?*

Have you or family members ever had mental health emergencies in the past?*

Crises such as: panic attacks, debilitating depression, suicidal feelings and/or attempts, any hospitalizations for mental health? If so, how long ago and what was the treatment for it?

Do your conflicts ever escalate beyond anything verbal?*

What time would be best in your schedule to meet for therapy?*

What would be the best style of communication for you?*

When speaking with your therapist would a more direct/challenging approach be best or a collaborative/supportive approach?

Is there a specific therapist you would prefer to work with?*

How did you hear about us?*

Is there anything else you would like us to know about you? Any other questions for us?*

Family Therapy – Intake Form