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Couples Intake
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Email
*
Your email
Client Name
Your answer
What led you to decide to come to couples therapy?
Your answer
How long have you and your partner been together? In what form (eg, dating, living together, married)?
Your answer
What do you hope to accomplish with couples counseling?
Your answer
What have you already done to deal with difficulties?
Your answer
What are your biggest strengths as a couple?
Your answer
Please rate your current level of relationship happiness on a scale of 1 to 5 with 1 being extremely unhappy and 5 being extremely happy
Extremely Unhappy
1
2
3
4
5
Extremely Happy
Clear selection
Have you received prior couples counseling? If yes, please list where and the outcome
Your answer
Have you ever been in individual counseling?
yes
no
Clear selection
Do either you or your partner drink alcohol or take drugs to intoxication? If yes, please list who, how often and what drugs or alcohol.
Your answer
Do you wish your partner would cut back on his/her drinking or drug use?
yes
no
n/a
Clear selection
Have either you or your partner struck, physically restrained, used violence or injured the other person? If yes, who, how often and what happened?
Your answer
Has either of you threatened to separate or divorce as a result of the current relationship problems? If yes, please list who
Your answer
If married, have either you or your partner consulted with a lawyer about divorce? If yes, list who.
Your answer
Do you perceive that either you or your partner has withdrawn from the relationship? if yes, list who.
Your answer
How enjoyable is your sexual relationship with 1 being unpleasant and 5 being extremely unpleasant
Unpleasant
1
2
3
4
5
Extremely pleasant
Clear selection
How satisfied are you with the frequency of your sexual relations with 1 being extremely unsatisfied and 5 being extremely satisfied?
Unsatisfied
1
2
3
4
5
Extremely satisfied
Clear selection
What is your current level of overall stress with 1 being no stress and 5 being high stress
No stress
1
2
3
4
5
High stress
Clear selection
Rank order the top 3 concerns you have in your relationship with your partner.
Your answer
Today's Date
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