GETTING STARTED FORM FOR COUPLES COUNSELING
THIS INFORMATION LEGALLY WILL BE KEPT COMPLETELY CONFIDENTIAL. THIS FORM WILL TAKE BETWEEN 7 TO 10 MINUTES TO COMPLETE.
Name
*
First Name
Last Name
What are your preferred pronouns?
*
Email
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ABOUT YOU AS A COUPLE
How would you describe your "status?"
*
Married
Separated
Divorced
Dating
Co-habitating
Living together
Living apart
Length of Time in Relationship:
*
Regarding the primary reason(s) that bring you to counseling, what is the overall level of concern at this point in time?
*
No concern
Little concern
Moderate concern
Serious concern
Very serious concern
Regarding the primary reason(s) that bring you to counseling, how frequently do you think about it?
*
No occurrence
Occurs rarely
Occurs sometimes
Occurs frequently
Occurs nearly always
What do you hope to accomplish through counseling?
*
0/100
What have you already done to deal with the difficulties?
*
0/100
What are your biggest strengths as a couple?
*
0/100
Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does.
*
0/100
Please rate your current level of relationship happiness by circling the number that corresponds with your current feelings about the relationship? (10 being EXTREMELY happy)
*
1
2
3
4
5
6
7
8
9
10
Have you received prior couples counseling related to any of the above problems?
*
Yes
No
If yes, when:
If yes, where:
If yes, by whom:
Length of treatment:
Problems Treated:
What was the outcome?
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 yes, give a brief summary of concerns that you addressed.
0/100
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.
Has either of you threatened to separate or divorce (if married) as a result of the current relationship problems?
*
Yes
No
If yes, Who?
Partner A
Partner B
Both of Us
If married, have either you or your partner consulted with a lawyer about divorce?
*
Yes
No
Not married
If yes, Who?
Partner A
Partner B
Both of Us
Do you perceive that either you or your partner has withdrawn from the relationship?
*
Yes
No
If yes, Who?
Partner A
Partner B
Both of Us
How frequently have you had sexual relations in the past month?
blanks
times.
How enjoyable is your sexual relationship? (10 being extremely enjoyable)
*
1
2
3
4
5
6
7
8
9
10
How satisfied are you with the frequency of your sexual relations? (10 being extremely satisfied)
*
1
2
3
4
5
6
7
8
9
10
What is your current level of stress (overall)? (10 being extremely stressed)
*
1
2
3
4
5
6
7
8
9
10
What is your current level of stress (in the relationship)?(10 being extremely stressed)
*
1
2
3
4
5
6
7
8
9
10
Rank order the top three concerns that you have in your relationship with your partner (1 being the most problematic):
*
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