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

Other
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
Frequency
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?
If Yes, When?
If Yes, Where?
If Yes, By Whom?
If Yes, Length of Treatment?
Problems Treated?
What was the outcome?
Have either you or your partner(s) been in individual counseling before? If so, give a brief summary of concerns that you addressed.
Give a brief summary of the concerns addressed
Do either you or your partner(s) drink alcohol to intoxication or take drugs to intoxication?
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?
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?
If Yes, Who?
If married, have either you or your partner(s) consulted with a lawyer about divorce?
If Yes, Who?
Do you perceive that either you or your partner(s) has withdrawn from the relationship?
If Yes, which of you has withdrawn?
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: