Couples Intake Form

Couples Intake Form
Individual Information

Please ensure that both partners complete the form below
Name

First NameMiddle NameLast Name
Nick Name/ Preferred Name
If Applicable
Administrative Sex:
Gender Identity:
Sexual Orientation:
Partner's Name

First NameMiddle NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Can we leave voice messages?
Email
example@example.com
Emergency Contact
Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Insurance Information
Insurance Name:
Insurance ID:
Group #:
If we are using your insurance, please fill out a Release of Information for your partner using this link, or ask for one at your first appointment:

********
Couples Information
Briefly describe what prompted you to seek counseling at this time:
Relationship Status (Check all the apply)
Length of time in current relationship:

Do you have children together? If so, please indicate information below:

Do you have children from previous relationships? If so, please indicate information below:

What are your biggest strengths as a couple?
Rank order the top three concerns you have in your relationship with your partner (1 being most problematic):
1:
2:
3:
Please suggest one thing you could personally do to improve the relationship, regardless of what your partner does:
Do either you or your partner drink alcohol or use drugs?
If yes for either partner, please list who, what is used, and how often:
What is your perception of your partner's drug/alcohol intake?
What do you think your partner would say about your drug/alcohol intake?
Have either your or your partner struck, physically restrained, used violence against, or injured the other person?
How comfortable are you if your partner spend free time away from you?
How frequently have you had sexual relations during the last month?
If 0, about how long has it been?

How open are you in expressing your innermost feelings, desires and thoughts to your partner?

	1	2	3	4	5	6	7	8	9	10

1 is Completely closed, 10 is Completely open

How much do you still love your partner?

	1	2	3	4	5	6	7	8	9	10

1 is Not at all, 10 is Very deeply

Decribe your level of commitment to your relationship:

	1	2	3	4	5	6	7	8	9	10

1 is Not at all, 10 is Extremely

Explain the rating you gave yourself for the question above:
Individual History Questions
Religious Preference
Have you ever received prior couples counseling or any prior individual counseling?
If yes, please indicate the following information:
When:
From whom:
Diagnosis:
Problems treated:
Where:
Length of treatment:
Was it helpful?
Has anyone in your family of origin been diagnosed with a mental illness? (Ex. anxiety, depression, etc.)

If yes, please list information below:

Do you have any medical conditions? (Ex. allergies, surgeries, heart problems, etc.)

Current Medication:

Please indicate your highest level of education:
How would you describe your current relationship with your family of origin? (Check all that apply)
If you have different relationships with each member, please list relationship with applicable adjectives:
Example: Sister - positive, close Father - strained, distant
Please list any legal issues you are currently involved in, or have been involved in the past:
Example: DUI, parental custody, divorce, etc.

Please list anyone who you would consider a support system for you:

Is there anything else that is important to know about and that you have not written about on these forms?
Should be Empty:

Individual Information