Family Wellness & Support Services Form

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Family Wellness & Support Services Form

Personal and Family Information

Full Name of each family member participating*

Phone*

Email*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Family Composition *

Emergency Contact Information*

Health and Wellness Information

Medical History*

Long answer

Mental Health History*

Current Wellness Challenges*

Specific areas of support needed*

Goals for Participation

Family wellness goals*

Individual goals for each participating family member*

Specific topics of interest for workshops or counseling*

Preferred Services and Support

Preferred types of support*

Availability*

Preferred format*

Previous Support or Services Used

Previous or current participation in wellness or counseling services (if applicable)*

Successes or challenges faced in past wellness efforts*

Consent and Confidentiality

Consent for counseling or group participation (required for minors, parental/guardian consent for children)

Consent

No Consent

Confidentiality agreement to ensure privacy during counseling or group sessions

Consent

No Consent

Emergency Needs and Crisis Support

Immediate concerns or urgent needs*

Referral needs *

Follow-Up and Ongoing Support Preferences

Interest in ongoing support*

Preferred method of communication for updates and follow-ups*

Phone Call

Email

Text

Commitment to Participation

Willingness to attend all scheduled sessions and actively participate in the program*

Yes

No

Agreement to provide feedback for program evaluation and improvement*

Yes

No

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