Dr. Destun & Associates

Psychologists in Private Practice

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Psychologists in Private Practice

January 2018 Currently Accepting Clients for Individual Therapy Only

Couple Therapy Intake Form

(Please complete one form each)

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Contact Information

Your Information:

(check if voicemail is OK)


Emergency Contact:



Physician Information

Family Doctor:



Psychiatrist (if applicable):


How did you find us?






Education and Employment

Employment:





Highest grade completed:

Family of Origin



Health History and Treatment












Current Habits

Please describe your current habits in each of the following areas. Please indicate frequencies/amounts and types where appropriate.








Primary Relationship





(unsatisfied)

(completely satisfied)



(unsatisfied)

(completely satisfied)



(unsatisfied)

(completely satisfied)



(unsatisfied)

(completely satisfied)



(unsatisfied)

(completely satisfied)















(not)

(extremely)



(not)

(extremely)



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