• Couples Intake Form

  • Relationship Status (check all that apply)*
  • As you think about the primary reason that brings you here, how frequently does it occur?*
  • As you think about the primary reason that brings you here, how would you rate your overall concern about it?*
  • Have you received prior counseling related to any of the above problems?*
  • Have either you or your partner been in individual counseling before?*
  • Do you or your partner drink alcohol to intoxication or take drugs to intoxication?*
  • If married, has either of you threatened to separate or divorce because of the current relationship problem? If not married, please answer N/A*
  • If married, have either you or your partner consulted with a lawyer about divorce? if not married, please answer N/A*
  • Have either you or your partner struck, physically restrained, used violence against, or injured the other person?*
  • Do you perceive that either you or your partner has withdrawn from the relationship?*

  • 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.

  • Should be Empty: