Length of time in current relationship: Years, months, days etc.
As you think about the primary reason that brings you here, how would you rate its frequency and your overall level of concern at this point in time?
If yes, When: Date Where: Name of agency By whom: First Name Last Name Length of treatment: Years, Months, Days EtcProblems treated: Problems
Rank order the top three concerns that you have in your relationship with your partner (1 being the most problematic):
Thank you for completing this. Please bring this with you during your first appointment. Please note that you will be asked to talk about your answers in sessions but your partner will not be shown this form.