Center for Anxiety - Couples Intake Form

Couples Intake Form
Name*
Name of Partner*
Relationship Status (check all that apply)*

MarriedSeparatedDivorcedDatingCohabitating / Living togetherLiving Apart
Length of time in current relationship*
As you think about the primary reason that brings you here, how frequently does it occur?*

No occurrenceOccurs rarelyOccurs sometimesOccurs frequentlyOccurs nearly always
As you think about the primary reason that brings you here, how would you rate your overall concern about it?*

No concernLittle concernModerate concernSerious concernVery serious concern
What do you want to accomplish through counseling?*
What have you already done/tried to deal with the difficulties?*
What are your biggest strengths as a couple?*
Please rate your current level of relationship happiness from a scale of 1-10 (1 = extremely unhappy, 10 = extremely happy)*
Have you received prior counseling related to any of the above problems?*

YesNo
If yes, when, where, and with whom?
If yes, what was the outcome? (i.e. problems were better, worse, same)
Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does*
Have either you or your partner been in individual counseling before?*

YesNo
Do you or your partner drink alcohol to intoxication or take drugs to intoxication?*

YesNo
If yes, please explain
If married, has either of you threatened to separate or divorce because of the current relationship problem? If not married, please answer N/A*

YesNoN/A
If married, have either you or your partner consulted with a lawyer about divorce? if not married, please answer N/A*

YesNoN/A
Have either you or your partner struck, physically restrained, used violence against, or injured the other person?*

YesNo
Do you perceive that either you or your partner has withdrawn from the relationship?*

YesNo
How frequently have you had sexual relations during the last month?*
How satisfied are you with the frequency of your sexual relationship? Please rate 1-10 (1 = extremely unhappy, 10 = extremely happy)*
How enjoyable is your sexual relationship? Please rate 1-10 (1 = extremely unpleasant, 10 = extremely pleasant)*
What is your current level of stress (overall)? Please rate 1-10 (1 = no stress, 10 = high stress)*
What is your current level of stress in the relationship? Please rate 1-10 (1 = no stress, 10 = high stress)*
Please list your top three concerns that you have in your relationship with your partner (1 being the most problematic)*
Is there anything else you would like me to know?
Thank you for completing this form. Please note that you may be asked to talk about your answers in appointments, but your partner will not be shown this form.
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