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Couples Intake Form For Cassandra
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33
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1
Name
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First Name
Last Name
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2
Current Relationship Status
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Check all that apply.
Married
Separated
Divorced
Dating
Cohabitating/ Living Together
Living Apart
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3
Length of time in current relationship:
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4
List your top 3 concerns that you have in your relationship with your partner:
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1 being the most problematic
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5
As you think about the primary reason that brings you here, how frequently does it occur?
*
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No occurence
Occurs sometimes
Occurs rarely
Occurs frequently
Occurs nearly always
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6
As you think about the primary reason that brings you here, how would you rate your overall concern about it?
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No concern
Little concern
Moderate concern
Serious concern
Very serious concern
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7
How long has this (the issue) been going on?
(i.e., 1 month, several months, since December 2021, etc.)
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8
What do you hope to accomplish through counseling?
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9
What have you already done to deal with the difficulties?
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10
Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does:
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11
What are your biggest strengths as a couple?
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12
Please rate your current level of relationship happiness by selecting the number that corresponds with your current feelings about the relationship:
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(1 Extremely Unhappy & 10 Extremely Happy)
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13
Have either you or your partner been in individual counseling before?
*
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YES
NO
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14
If married, has either of you threatened to separate or divorce as a result of the current relationship problems?
*
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YES
NO
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15
Have either you or your partner struck, physically restrained, used violence against, or injured the other person?
*
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YES
NO
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16
Do either you or your partner drink alcohol to intoxication or take drugs to intoxication?
*
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YES
NO
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17
Have either you or your partner cheated or had an affair (whether past or present) that you are aware of?
*
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YES
NO
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18
If there was an affair, was it you or your partner that cheated/had the affair? Is it ongoing or has it ended? What was the duration of the affair?
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19
Do you perceive that either you or your partner has withdrawn from the relationship?
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YES
NO
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20
If married, have either you or your partner consulted with a lawyer about divorce?
YES
NO
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21
How frequently have you had sexual relations during the last month?
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22
How satisfied are you with the frequency of your sexual relations?
(1 Extremely Unsatisfied & 10 Extremely Satisified)
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23
How enjoyable is your sexual relationship?
(1 Extremely Unpleasant & 10 Extremely Pleasant)
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24
What is your current level of stress (overall)?
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(1 No Stress & 10 High Stress)
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25
What is your current level of stress (In the relationship)?
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(1 No Stress & 10 High Stress)
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26
Have you received prior couples counseling related to any of the above problems?
*
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YES
NO
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27
When did this occur?
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28
Who counseled you?
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29
What was the length of treatment?
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30
What were the problems that were treated?
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31
What was the outcome?
Much worse
Somewhat worse
Stayed the same
Somewhat successful
Very successful
N/A
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32
Today's Date
-
Date
Year
Month
Day
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33
Who filled out this form?
First Name
Last Name
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