713.524.0142
1801 Lexington St.
felixscardino@sbcglobal.net
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You have the option of filling out our Intake form right here online
or you can print out the form by clicking here.

Client Intake Form

1801 Lexington
Houston, TX 77098

Client
Name *
Address *
City *
State *
ZIP *
Phone *
Birthdate *
SS# *
Level of Education *
Birthplace *
Religion *
Employment
Occupation *
Business Name *
PositionHeld *
Length of Time Employed *
Phone *
Cell Phone
Email *
Spouse
Name
Address
City
State
ZIP
Phone
Birthdate
SS#
Level of Education
Birthplace
Religion
Employment
Occupation
Business Name
PositionHeld
Length of Time Employed
Phone
Cell Phone
Children
Name Age Living at Home From Present or Previous Marriage

Marital Status
Single  Married  Separated  Divorced  Widowed*
Date of Status 
List Previous Marriages Date: From-To

Health Information
Do you have any significant physical health problems/complications?
Yes No*
Do you use any medication?
Yes No*
Have you been in psychotherapy before?
Yes No*
Who referred you for counseling?
In case of an emergency someone we may contact who is not a member of your immediate household
Name *  Phone *  Cell 
Family Diagnostic Inventory (please choose the appropriate number)
Areas of Concern Very Dissatisfied Very Satisfied
Social Activities
1 2 3 4  5 6 7 8 9 10
Money Matters
1 2 3 4  5 6 7 8 9 10
Sexual Experience
1 2 3 4  5 6 7 8 9 10
Career/Job
1 2 3 4  5 6 7 8 9 10
Religion
1 2 3 4  5 6 7 8 9 10
Talking Communication
1 2 3 4  5 6 7 8 9 10
Household Chores/Resonsibilities
1 2 3 4  5 6 7 8 9 10
Decision Making Progress
1 2 3 4  5 6 7 8 9 10
Alcohol/Drugs
1 2 3 4  5 6 7 8 9 10
Health/Medicine/Drugs
1 2 3 4  5 6 7 8 9 10
My Independence
1 2 3 4  5 6 7 8 9 10
Rearing/Discipline of Children
1 2 3 4  5 6 7 8 9 10
Marital/Family Goals and Values
1 2 3 4  5 6 7 8 9 10
Relatives/In-Laws
1 2 3 4  5 6 7 8 9 10
Spouse's Independence
1 2 3 4  5 6 7 8 9 10
Leisure Time/Hobbies
1 2 3 4  5 6 7 8 9 10
Vacations
1 2 3 4  5 6 7 8 9 10
Food - Shopping, Cooking, Eating Out
1 2 3 4  5 6 7 8 9 10
Emotional Closeness
1 2 3 4  5 6 7 8 9 10
General Marital Satisfaction
1 2 3 4  5 6 7 8 9 10
Center Policies

You will be charged for cancelled appointments unless notice is received at least 24 hours prior to the appointment time so that the time may be scheduled for another client.

We request that you pay at the time of each visit.

If using insurance, complete the insurance form provided.

You will receive a monthly statement for your records.

There will be a charge for phone consultations exceeding 15 minutes.

I understand and accept the policies concerning cancellation of appointments, billings, insurance statements and phone consultations. I will be resonsible for payment.

Client Signature: *

Submit
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