Couples Counseling Snapshot Form
Please fill out in entirety below.
Your Name
*
First Name
Last Name
Partner's Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
This is my # long-term committed relationship/marriage
*
1st
2nd
3rd
4th
We have known each other for _____ years
*
We have been married/in a committed relationship for _____ years
*
List all the children you have/share (names, ages & genders):
What is the main reason you are coming with your partner for counseling?
Major challenges of the relationship?
Major strengths of the relationship?
How would you describe your partner?
How would your partner describe you?
How do you sabotage your relationship with your partner?
Have you or your partner had an affair during this relationship?
If yes, does the partner know?
Have all ties since been severed?
Do you or your partner have any known addictions?
If so, please describe.
Is there or has there been emotional/mental violence in your relationship?
If so, describe.
Is there or has there been physical or sexual violence in your relationship?
If so, describe.
Submit
Should be Empty: