MHCS Couples and/or Family Intake Form
Please fill out the following information from your perspective.
Date:
*
/
Month
/
Day
Year
Name:
*
Pronouns:
Name of Partner:
*
Partner's Pronouns:
Type of work:
*
Education Level:
*
Please Select
Less than a high school diploma
High school graduate/GED, no college
Some college or associate degree
Bachelor's degree and higher
Please outline any significant individuals involved in the relationship, including age, pronouns, and their relationship to the couple (e.g., family members, close friends, etc.):
*
Please describe the family constellation, including who lives in the household and the roles of household members:
Household member(s):
*
Role of household member(s):
*
Please note any addition information regarding family constellation here:
Home Setting:
*
Rent (apartment/house)
Own (house/condo)
Group Home
Foster Care
Other
Relationship Status: (check all that apply)
*
Married
Separated
Divorced
Dating
Cohabitating
Living together
Living apart
Length of time in current relationship:
*
Brief history of current 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 concern
Little concern
Moderate concern
Serious concern
Very serious concern
Frequency
*
No occurrence
Occurs rarely
Occurs sometimes
Occurs frequently
Occurs nearly always
What relational issues would you like to address? (Please rank in order from most to least problematic)
*
What have you already done to deal with the difficulties?
*
What goals would you like to achieve as a couple?
*
What are your strengths as a couple?
*
Please rate your current level of relationship happiness by selecting the number that corresponds with your current feelings about the relationship.
*
Extremely unhapppy
1
2
3
4
5
6
7
8
9
Extremely happy
10
1 is Extremely unhapppy, 10 is Extremely happy
Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does.
*
Have you received prior couples counseling related to any of the above problems?
*
Yes
No
If yes, when?
Where?
By whom?
Length of treatment:
Problems treated:
What was the outcome? (check one)
Much worse
Somewhat worse
Stayed the same
Somewhat successful
Very successful
Have either you or your partner been in individual counseling before?
*
Yes
No
If so, give a brief summary of concerns that you addressed.
Do either you or your partner drink alcohol to intoxication or take drugs to intoxication?
*
Yes
No
If yes for either: who, how often, and what drugs or alcohol?
Have either you or your partner struck, physically restrained, used violence against or injured the other person?
*
Yes
No
If yes for either: 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?
*
Yes
No
If yes, who?
Me
Partner
Both of us
If married, have either you or your partner consulted with a lawyer about divorce?
*
Yes
No
Not applicable
If yes, who?
Me
Partner
Both of us
Do you perceive that either you or your partner has withdrawn from the relationship?
*
Yes
No
Not applicable
If yes, which of you has withdrawn?
Me
Partner
Both of us
How frequently have you had sexual relations during the last month?
*
times
How enjoyable is your sexual relationship?
*
Extremely unhapppy
1
2
3
4
5
6
7
8
9
Extremely happy
10
1 is Extremely unhapppy, 10 is Extremely happy
How satisfied are you with the frequency of your sexual relations?
*
Extremely unhapppy
1
2
3
4
5
6
7
8
9
Extremely happy
10
1 is Extremely unhapppy, 10 is Extremely happy
What is your current level of stress (overall)?
*
No stress
1
2
3
4
5
6
7
8
9
High stress
10
1 is No stress, 10 is High stress
What is your current level of stress (in the relationship)?
*
No stress
1
2
3
4
5
6
7
8
9
High stress
10
1 is No stress, 10 is High stress
Lastly, are the any pivotal or significant events in your relationship you would like to outline? If so, please provide a timeline and description of events below.
*
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