Couples Counseling Intake

Couples Counseling Intake

Please submit one for yourself and then forward the link to your partner to complete their own form. Note: Your answers will save and be visible until you hit "submit."
Name

First Name Last Name
Partner's Name

First Name Last Name
Each of you will need to submit his/her own form. Please do not share your answers with one another or discuss them.
Text this form to my partner at the number below:
Please enter a valid phone number.
OR
Email this form to my partner at the email below:
example@example.com
Relationship Status

Married Separated Divorced Dating Living Together Living Apart
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 level of concern at this point in time?

No concern Little Concern Moderate Concern Serious Concern Very Serious Concern
Frequency: How often do you think about your relationship difficulties?

Rarely Sometimes Frequently Nearly all the time
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 happiness with your relationship:

Extremely unhappy Unhappy Neutral Happy 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 participated in couples counseling before with your current partner?

Have either of you been in treatment for mental health or substance abuse before? If so, give a brief summary of the concerns you addressed:
Do either you or your partner drink alcohol to intoxication or take drugs to intoxication? 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? If yes for either, who, how often and what happened?
Have either of you threatened to separate or divorce (if married) as a result of the current relationship problems?

Yes No
If yes, who?

On a scale of 1-10 how enjoyable is your sexual relationship? (1 being extremely unpleasant through 10 extremely pleasant?) 0 indicates you have stopped engaging in sexual relations entirely or you are unable to remember the last time you did.
On a scale of 1-10 how satisfied are you with the frequency of your sexual relations? (0 being extremely unsatisfied through 10 extremely satisfied.
On a scale of 0-10 what is your current overall level of stress in life? (0 being no stress through 10 high stress)
On a scale if 0-10 what is your current level of stress in your relationship?
Rank order the top 3 concerns you have in your relationship with your partner (1 being the highest concern):
Thank you for completing this. Please note that you may be asked to talk about your answers in sessions, but your partner will not be shown this form.
Should be Empty: