Metapsychotherapy Couple's Intake Form

Transforming Relationships is dedicated to handling personal information in compliance with the EU's General Data Protection Regulation (GDPR), and the Australian Privacy Act of 1988.

Name*

First NameLast Name

Birth Date*

MonthDayYear

Gender

What are your preferred pronouns?

Relationship Status

Email*

Number*

Country CodeArea CodePhone Number

Is it okay to e-mail you?*

YesNo

Is it okay to leave you messages?*

YesNo

Current Occupational Status

How were you referred to us?

What are your reasons for seeking couple's therapy at this time?

What do you hope a couple's session will help you resolve?

The following information will guide us to better understand you in a comprehensive, systemic way. Some of these questions may be difficult, challenging, or triggering to answer.

How many relationships have you had prior to this one? How long were they? How did they end?

Do you have children (biological, stepchildren, adopted)?

If yes, please give their ages and a brief description.

Have you had a child die?

If yes, please include how, and their ages.

Were your parents married? Did they get divorced? Are there any other important details about their relationship?

Were you adopted?

If yes, at what age? Do you know your birth parents?

Do you have any siblings?

If yes, how many? What are their ages and birth order?

Have any of your parents or siblings died?

If yes, please indicate name, cause, and date of death.

Have you had any previous counseling individually, or as a couple?

If yes, please indicate from whom, for what, and its effects.

Have you attempted suicide or had suicidal thoughts?

If yes, at what age? Please provide the name of your current physician.

Please list any medications, herbal, or homeopathic treatments you are taking and the conditions they are meant to treat.

The following information will guide us to better understand your current personal wellbeing.

I am currently experiencing the following behaviours.

I am currently experiencing the following feelings.

I am currently experiencing the following physical symptoms

Thank you for sharing this information, especially the difficult or challenging parts. All information will be handled as per our Privacy Policy

MetaPsychotherapy PTY LTD

ACN 666 077 185 ABN 40 666 077 185

Metapsychotherapy Couple's Information Form

Partner 1

Relationship Background

Family Background

History

Current Experiences

Partner 2

Relationship Background

Family Background

History

Current Experiences