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SLCS Intake Form
Silver Lining Counseling Services
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* Indicates required question
Name
*
Your answer
Partner's Name
Your answer
Today's Date
MM
/
DD
/
YYYY
Relation Status (check all that apply)
Married
Separated
Divorced
Dating
Cohabitating
Living Apart
Time in current relationship
Your answer
What is the primary reason that brings you to therapy?
Your answer
What do you hope to accomplish through Therapy
Your answer
What has been done to deal with the current challenges
Your answer
What are your strengths as a couple?
*
Your answer
Have you previously received couple's counseling?
Yes
No
Clear selection
Have you and your partner ever received individual counseling?
Yes
No
Have you or your partner drank alcohol to intoxication or taken drugs to intoxication?
Yes
No
Clear selection
Has there been a history of physical or verbal violence towards one another?
Yes
No
Clear selection
If so, please provide an explanation
Your answer
Has either of you threatened to separate or divorce as a result of your challenges?
Yes
No
Have you or your partner consulted with an attorney about divorce?
Yes
No
Clear selection
Have either you or your partner withdrawn from the relationship?
Yes
No
Clear selection
How frequently have you and your partner had sexual relations within the past month?
Your answer
How enjoyable is your sexual relationship
extremely unsatisfied
1
2
3
4
5
6
7
8
9
10
extremely satisfied
Clear selection
What is your current level of stress (overall)?
(no stress)
1
2
3
4
5
6
7
8
9
10
(high stress)
Clear selection
What is your current level of stress (in the relationship)?
(no stress)
1
2
3
4
5
6
7
8
9
10
(high stress)
Clear selection
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