COUPLES INTAKE FORM
Please complete the SECURE on-line form below.
Name of partner
Length of time in current relationship
As you think about the primary reason that brings you here, how would you rate its frequency and your overall llbevel of concern at this point in time?
Very serious concern
Occurs nearly always
What do you hope to accomplish through counseling?
What have you already done to deal with difficulties?
What are your biggest strengths as a couple?
Please make at least one suggestion as to something you could personally do to lmprove the relationship Wregardless of what your partner docs.
Have you received prior couples counseling related to any of the above problems?
What was the outcome(check one)?
Stayed the same
Have either you or your partner been in individual counseling before?
If so, give a brief summary of concerns that you addressed.
Do either you or your partner drink alcohol to intoxication or take drugs to intoxication?
If yes for either,‘ who, how oﬁen and what drugs or alcohol?
Have either you or your partner struck, physically restrained, used violence against or injured the other person?
If yes for either, who, how often and what happened.
Rank order ‘the top three concerns that you have in your relationship with your partner (1 being the most problerrnatic):
Should be Empty: