Relationship Counselling - Individual Intake

Barefoot Vibes: Relationship Counselling Intake Form (Individual)

Please complete this form individually and honestly before your first counselling session. Your answers will help the counsellor understand your perspective and support you both effectively. All responses are confidential.

1 Full name*

3 Gender/pronouns (optional)*

4 Occupation

5. Contact number*

Address - please provide address for session (if relevant to you)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Section 2: Background & Relationship Context

7 How long have you been in your current relationship?*

8 Are you married, de facto, engaged or other?*

9 Do you live together? If yes for how long*

10 Do you have children together? Yes/No If yes how many and ages?*

11 Do either of you have children from previous relationships? Yes/No If yes please specify?

12 What brings you to relationship counselling at this time?*

13 What do you feel are the main challenges in your relationship right now?*

14 How do you usually handle conflict as a couple?*

15. On a scale of 1-10, how would you rate your current satisfaction in the relationship?

1 = very dissatisfied, 10 = very satisfied*

16 What do you see as the strengths of your relationship?*

Section 4: Individual Perspectives

17 How do you feel your partner sees the issues in your relationship?*

18 What do you personally want to change or improve?*

19 What role do you feel you play in the current challenges?*

20 How do you usually feel during conflicts eg shut down, angry, anxious, avoidant?*

21 What are your goals for counselling?*

22 What would a positive outcome look like for you?*

23. Are you open to making changes yourself, not just expecting your partner to change?*

YesNo

24. Have you ever experienced physical, emotional, or verbal abuse in this relationship?*

YesNo

If yes, please explain only as much as you feel comfortable

25. Do you feel safe in your relationship?*

YesNo

26. Do you or your partner use alcohol or substances in a way that affects your relationship?*

YesNo

Section 7: Practical Considerations

27 Are there any specific topics you want to make sure are discussed in counselling?

28 Are there any cultural religious or personal values you would like me to be aware of?

29 Do you have any preferences for session times, day, evening, weekend?

Section 8: Consent & Commitment

30. Do you agree to attend counselling in good faith, being respectful and open during sessions?*

YesNo

31. Are you open to do homework, reflection, or practice strategies between sessions?*

YesNo