Couples Counseling

Couples Counseling

Initial Intake Form
Client Name *

First Name Last Name
Date *

Month Day Year
Date
Name of Partner *

First Name Last Name
Relationship Status: (check all that apply) *

Married Separated Divorced Dating Cohabitating Living together Living apart
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?
Concern *

No concern Little concern Moderate concern Serious concern Very serious concern
Frequency *

No occurrence Occurs rarely Occurs sometimes Occurs frequently Occurs nearly always
What do you hope to accomplish through counseling? *
What have you already done to deal with the difficulties? *
What are your biggest strengths as a couple? *
Please rate your current level of relationship happiness by clicking on the number that corresponds with your current feelings about the relationship *

1

2

3

4

5

6

7

8

9

10

1 is extremely unhappy, 10 is extremely happy
Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does. *
Have you received prior couples counseling related to any of the above problems? *

Yes No
If yes, When:   Date Where:    Name of agency
By whom:   First Name Last Name  Length of treatment:  Years, Months, Days Etc
Problems treated:   Problems
What was the outcome (check one)? *

Very successful Somewhat successful Stayed the same Somewhat worse Much worse
Have either you or your partner been in individual counseling before? *

Yes No
If yes, give a brief summary of concerns that you addressed.
Do either you or your partner drink alcohol to intoxication or take drugs to intoxication? *

Yes No
If yes for either, who, how often and what drugs or alcohol?
Have either you or your partner struck, physically restrained, used violence against or injured the other person? *

Yes No
If yes for either, who, how often and what happened.
Has either of you threatened to separate or divorce (if married) as a result of the current relationship problems? *

Yes No
If yes, who?

Me Partner Both of us
Do you perceive that either you or your partner has withdrawn from the relationship? *

Yes No
If yes, which of you has withdrawn?

Me Partner Both of us
How frequently have you had sexual relations during the last month? *
How enjoyable is your sexual relationship? *

1

2

3

4

5

6

7

8

9

10

1 is extremely unpleasant, 10 is extremely pleasant
How satisfied are you with the frequency of your sexual relations? *

1

2

3

4

5

6

7

8

9

10

1 is extremely unsatisfied, 10 is extremely satisfied
What is your current level of stress (overall)? *

1

2

3

4

5

6

7

8

9

10

1 is no stress, 10 is high stress
What is your current level of stress (in the relationship)? *

1

2

3

4

5

6

7

8

9

10

1 is no stress, 10 is high stress
Rank order the top three concerns that you have in your relationship with your partner (1 being the most problematic):
1. *
2. *
3. *
Lastly, please draw a graph indicating your level of relationship satisfaction beginning with when you met your partner. Note pivotal/significant events in your relationship (e.g., one of you moved out, one of you cheated). *
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.
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