Relational Therapy Initial Intake Form

Relational Therapy Initial Intake Form
Your Name*

First NameLast Name
Relationship structure/identity with______*

First NameLast Name
Today's Date*

MonthDayYear
Date
Relationship Status*

MarriedSeparatedDivorcedDatingCohabitatingLiving togetherLiving apartOther
Length of Time In Relationship*
As you think about the primary reason that brings you here, how would you rate its frequency and your overall level of concern at this point in time?
Concern*

No concernLittle concernModerate concernSerious concernVery serious concern
Frequency*

No occurrenceOccurs rarelyOccurs sometimesOccurs frequentlyOccurs nearly always
What do you hope to accomplish through counseling?*
What have you done to already deal with the difficulties?*
What are your biggest strengths within your relationship?*
Please rate your current level of relationship happiness by circling the number that corresponds with your current feelings about the relationship.*

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner(s) does.*
Have you received prior couples counseling related to any of the above problems?*

YesNo
If Yes, When?
If Yes, Where?
If Yes, By Whom?
If Yes, Length of Treatment?
Problems Treated?
What was the outcome?

Very successfulSomewhat successfulStayed the sameSomewhat worseMuch worseN/A
Have either you or your partner(s) been in individual counseling before? If so, give a brief summary of concerns that you addressed.*

YesNo
Give a brief summary of the concerns addressed
Do either you or your partner(s) drink alcohol to intoxication or take drugs to intoxication?*

YesNo
If yes for either, who, how often and what drugs or alcohol?
Have either you or your partner(s) struck, physically restrained, used violence against or injured the other person?*

YesNo
If yes, 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?*

YesNo
If Yes, Who?

MePartner(s)Both of us
If married, have either you or your partner(s) consulted with a lawyer about divorce?*

YesNo
If Yes, Who?

MePartner(s)Both of us
Do you perceive that either you or your partner(s) has withdrawn from the relationship?*

YesNo
If Yes, which of you has withdrawn?

MePartner(s)Both of us
How frequently have you had sexual relations during the last month?*
How enjoyable is your sexual relationship?*

1

2

3

4

5

6

7

8

9

10

1 is Extremely Unenjoyable, 10 is Extremely Enjoyable
How satisfied are you with the frequency of your sexual relations?*

1

2

3

4

5

6

7

8

9

10

1 is Extremely Unsatisfied, 10 is Extremely Satisfied
What is your current level of stress (overall)?*

1

2

3

4

5

6

7

8

9

10

1 is Extremely Unstressed, 10 is Extremely Stressed
What is your current level of stress (in the relationship)?*

1

2

3

4

5

6

7

8

9

10

1 is Extremely Unstressed, 10 is Extremely Stressed
Rank order the top three concerns that you have in your relationship with your partner(s) (1 being the most problematic):*
Should be Empty: