Couples Counselling Intake Form
Name
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred methods of contact
*
Phone
Email
Text
All of the above
Do you have children? If yes, list their ages
Would you prefer online or face to face?
*
Describe your family background
*
How did you meet, and what brought you together as a couple?
*
What were the happiest times in your relationship?
*
How do you manage stress individually and as a couple?
*
What challenges have you faced together, and how did you overcome them?
*
What strengths do you see in the relationship?
*
How do you typically resolve a conflict? Please provide an example
*
How do you communicate your needs and feelings to each other?
*
What motivated you to seek therapy right now?
*
How would you rate your mental health and well-being right now - (1 low - 10 high)
*
1
2
3
4
5
6
7
8
9
10
What are your goals for therapy?
*
Do you have any specific fears about your relationship or its future?
*
Do you have any questions or concerns?
*
Signature
Submit
Should be Empty: