CLIENT INTAKE FORM First Name Last Name Age Gender GenderMaleFemale Phone No E-mail D.O.B Marital Status Marital StatusYesNo Do/So/Wo/Ho Number Of Children Educational Qualification Occupation Address Family Type (Nuclear/Joint/Extended/Singal Parent Family/Step Family/Grandparent Family/Childless Family) No Of Siblings Accompanying Person Name Relationship With Client Referred By Emergeny Contact Name Phone No Reason For Referral Reason For Referral Couple Therapy Child Therapy Behaviour Therapy Family Therapy Individual Therapy Other Psychological Therapy Additional Comment Does the patient have medical and/or psychiatric history Does the patient have medical and/or psychiatric history Yes No If Yes, Mention Date 7 + 4 = Submit