Application for Couples Therapy

Thank you for your interest in couples therapy.

Couples therapy is not appropriate for every relationship situation. Before accepting a referral, I ask all prospective clients to complete a screening questionnaire to help determine whether this service is clinically appropriate.

This form must be completed individually and independently by each partner.

Some questions are personal in nature. You are welcome to skip any question or discontinue the questionnaire at any time. However, if insufficient information is provided, I may be unable to assess suitability and your referral may not proceed.

Only the screening questions are mandatory.

Please use your discretion when responding to sensitive questions. If you are uncertain about sharing particular information, it is perfectly acceptable to leave that question unanswered. Additional information can be provided at a later stage if your application proceeds.

Completion of this questionnaire does not guarantee acceptance into couples therapy.

The purpose of this screening process is to assess whether couples therapy is appropriate for your circumstances at this time.

Your responses are confidential and will not be shared with your partner or any third party, except where disclosure is required by law or professional ethical obligations.

Records associated with this enquiry may be retained for 10 years in accordance with professional record-keeping requirements.

If couples therapy is assessed as unsuitable, this should not be interpreted as a judgement about either individual or the relationship itself. Rather, it reflects a clinical assessment regarding the suitability of this particular service.

Thank you for taking the time to complete this questionnaire. You will be contacted once the screening process has been reviewed.

Name

First Name

Last Name

Email* This field is required.

example@example.com

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Please indicate how you currently feel?* This field is required.

I want to make this relationship work

I am not sure whether this relationship can work, but I'm willing to see if it can

I don't want to be in this relationship, and I need support to leave in a way that minimises the distress for everyone involved

If you have children, please indicate their ages

What is your age?

How did you meet your partner?

How long have you been together?

What is your profession / occupation?

From your perspective, what is the context that has led you to decide to attend relationship therapy now?

Was there a time when this problem did not exist? How long has this been a problem?

Have you had relationship therapy with your partner before? What was helpful (or unhelpful) about it?

What are the hardest things for you to talk with your partner about?

Has there been any infidelity or inappropriate sexual behaviour which has made you uncomfortable in the relationship? If so, please say a little about this.

Is your relationship open? (i.e. Do you have a consensual agreement whereby you can see other people for romantic or sexual encounters?)

How are you currently feeling about sex with your partner?

How often do you have sex?(e.g. once a week, once a fortnight, once a month, once every few months)

Are there any specific sexual concerns or issues you would like to address in therapy? (i.e. Pelvic pain, endometriosis, incontinence, menopause, erectile dysfunction, coming too soon, not coming at all)

Is there physical violence present in your relationship with your partner?* This field is required.

YESNO

Do you have family violence or narcissistic abuse in your family of origin?

Do you have mental health issues in your family of origin, if so, what were these?

Do you have drug or alcohol abuse in your family of origin?

Have you been impacted by childhood trauma? (examples: physical, sexual, psychological, or emotional abuse or neglect, school "bullying", violence, poverty, racism, intergenerational trauma)

Are you having an affair? (emotional / sexual)* This field is required.

YESNO

Do you have a suspected or diagnosed neurodivergence? (i.e. ADHD, dyslexia, dyspraxia, Autism Spectrum Disorder)

YESNO

Do you have a suspected or diagnosed mental health issue?* This field is required.If so please clarify what this is, how long you have been impacted by it, and what has helped you?

Does your partner have a suspected or diagnosed mental health issue?* This field is required.If so please clarify what this is, how long they have been impacted by it, and what has helped them - if anything?

Does your partner have a suspected or diagnosed neurodivergence? (i.e. ADHD, dyslexia, dyspraxia, Autism Spectrum Disorder)

YESNO

Do you currently misuse alcohol, recreational drugs, or prescription medication, sex, or food to cope with everyday life?* This field is required.

Does your partner misuse alcohol, recreational drugs, prescription medication, sex, or food to cope with everyday life?* This field is required.

YESNO

Do any of the following apply to your partner?* This field is required.

Your partner's relationships with ex-partners, friends, family, or colleagues, are often very intense, difficult, or end abruptly

Your partner sometimes engages in efforts to avoid real or imagined abandonment by people who are close to them

Your partner's emotions change very quickly, where they seem to experience intense episodes of sadness, irritability, or anxiety

Your partner's level of anger often seems inappropriate, intense, or difficult to control

Your partner sometimes has suspicious or paranoid ideas (e.g., falsely believe that others are plotting to cause them harm in some way)

Your partner can be hypersensitive even to gentle feedback or setbacks leading to them becoming defensive or withdrawn

Your partner usually blames others for things not going well. They rarely accept responsibility for the part they may have played

None of the above

What are the issues with conflict?

We don't have it so nothing gets aired or sorted out

We can't repair the rupture(s)

The conflict escalates or becomes mean or volatile

We have conflict about everything and anything - there tend not to be themes

Our conflict centers around several core themes

The what we have conflict about is not bothering me so much, it's the way we do conflict that's an issue

We tend to have conflict about the relationship itself (i.e. not feeling loved, desired, appreciated, important, special, protected)

We rug sweep / avoid conflict

We can't communicate at the best of times

Imagine a genie visits you right now. The genie says to you: "Go on. Rub my lamp.... and I will grant you 3 wishes." What 3 wishes - if any - would you choose regarding changes you wish your partner would make?

Imagine a genie visits your partner. The genie says to your partner: "Go on. Rub my lamp.... and I will grant you 3 wishes." What 3 wishes - if any - would your partner choose regarding changes they wish you would make?

What does your partner do in times of conflict?Most people do a "two-step" wherein they start with one behaviour then switch when the conflict changes shape.

Shuts down (flees)

Becomes beligerent or demanding or confrontational (fights)

Runs away (flees)

Tries to fix things and make me feel better (fawns)

What conflict? (avoids)

Controls or nags or micromanages (anticipates)

Holds onto stuff and then becomes resentful and then blows up (avoids)

Withdraws into themselves and it's hard to read them or reach them (flees)

Says mean stuff that they then regret (fights)

Apologises just to keep the peace or stop the conflict (fawns)

What do you do in times of conflict?Most people do a "two-step" wherein they start with one behaviour then switch when the conflict changes shape.

Shut down (flee)

Become beligerent or demanding or confrontational (fight)

Run away (flee)

Try to fix things and make them feel better (fawn)

What conflict? (avoid)

Control or nag or micromanage (anticipate)

Hold onto stuff and then become resentful and then blow up (avoid)

Withdraw into yourself and it's hard to read you or reach you (flee)

Say mean stuff that you then regret later (fight)

Apologise just to keep the peace or stop the conflict (fawn)

How does your partner prefer to process emotional material?

They can process things pretty fast and give a rapid response - they seem to understand their feelings and their emotions pretty well most of the time

They seem to need time to digest what I have said, otherwise they can feel overwhelmed / pressured / anxious / controlled / confused

How do you prefer to process emotional material?

I can process things pretty fast and give a rapid response - I understand my feelings and my emotions pretty well most of the time

I need time to digest what I have heard otherwise I can feel overwhelmed / pressured / anxious / controlled / confused

If sexual intimacy is an issue for you, what do you think are contributing factors?

I have responsive desire and my partner has spontaneous desire

I have spontaneous desire and my partner has responsive desire

Not enough time or energy in the day

Medical issues

Feel disconnected due to the conflict between us

Feel disconnected due to the lack of emotional intimacy between us

Feel resentful about other stuff or other people in our life

Different shifts / rhythms with work or sleep

Infidelity

Online sex / pornography use

I'm too anxious about initiating in case I get rejected

I don't want my affection to be misread as flirtation

Sex would be cool but it's the affection that's missing that's hurting

Are there any other important details about your relationship history or personal circumstances that you would like your therapist to know?

What's the best number for Serafin to call you on?

What is your partner's name? (First and Last)* This field is required.(we need this information if you are applying for couples therapy to cross-reference and pair your individual applications thank you)

Do you want to request for a copy of this form?

YESNO

Purchase a copy of your questionnaire.Use for your own learning and reflection or share with your partner or your chosen therapist.

My Bag

I want to have my own copy
A copy will be sent to you within 48 working hours
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Application for Couples Therapy