COUPLES INTAKE FORM
Please complete the SECURE on-line form below.
Name
Date
-
Month
-
Day
Year
Date
Name of partner
Relationship Status:
Married
Separated
Divorced
Cohabitating
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 llbevel of concern at this point in time?
No concern
Little concern
Moderate concern
Serious concern
Very serious concern
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 difficulties?
What are your biggest strengths as a couple?
Please make at least one suggestion as to something you could personally do to lmprove the relationship Wregardless of what your partner docs.
Have you received prior couples counseling related to any of the above problems?
Yes
No
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 so, 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 ofien 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.
Rank order ‘the top three concerns that you have in your relationship with your partner (1 being the most problerrnatic):
Submit
Should be Empty: