Relationship Coaching Intake Form

Relationship Coaching Intake Form
Welcome to Passionate Awakenings Coaching!
• Please fill out this form using a PC. There are fields and features that will not work well on mobile devices. If this is not possible, use what you have and do what you can.
• Most sessions are attended using Zoom. You and your partner can be sitting in front of the same computer, or each at your own computers.
• Sessions are recorded unless otherwise requested. Both partners will receive the recording and an AI generated summary.
• I know there is a lot in this form. Take your time and make it an opportunity to reflect on your relationship. This information allows me to help you get the best outcome possible.
Personal & Contact Information
Client Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Age*
Cell Phone*
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Referral Name

First NameLast Name
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mailHome PhoneCell PhoneText
Spiritual/Philosophical Orientation*
Occupation*
Employment*
Employer/School*
Emergency Contact Information
Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Relationship*
Confidentiality and Truthfulness

This form contains sensitive questions below. Confidentiality is a top value and will be maintained in accord with the terms of service. Truthful answers greatly support your best outcome. If you want any of your answers to be kept confidential from your partner, please explain in the final comments and concerns field.
Relationship Information
Relationship Status*
Relationship Type*
FemaleMaleOther
FemaleMaleOther
Sexual Preference/Sexual Self-Definition*
Partner Name*

First NameLast Name
YesNoSometimes
Length of Relationship*
No minor childrenWe have minor children from this relationshipI have minor children, not from this relationshipPartner has minor children, not from this relationship
NoYesPart time
Please describe children: number, ages, sexes, parentage, custody:*
Mental Health & Medical History

(David is not a therapist, psychologist, doctor, or medical professional)
NoDailyWeeklyLessFormer User
NoDailyWeeklyLessFormer User
Please explain your use of recreational drugs & consciousness altering substances:*
ADHDAdoptedAlcoholismAutism SpectrumDepressionDevelopmental DelayLearning DisabilityMental Disorder DiagnosisOther
Please explain Mental Health History:*
NoYesMaybe/Not Sure
Please explain the substance problem and your desired outcome:*
YesNo
Please explain Medical Health Issues:*
YesNo
Please specify medication(s):*
5 hours or less6 hours7 hours8 hours9 hours10 hours or more
Typical Sleep Quality*
Typical Physical Activity Level*
Relationship Coaching Information
What are your biggest strengths as a couple?*
What do you hope to accomplish through relationship coaching?*
What have you already done to address difficulties?*
How happy are you currently with this relationship.*
Rate the current quality of engagement with efforts to improve relationship.*
How enjoyable is your sexual relationship?*
How satisfied are you with the frequency of your sexual relations?*
What is your current level of stress (in the relationship)?*
What is your current level of stress (overall)?*
Please name at least one thing you could personally do to improve the relationship regardless of what your partner does:*
YesNo
YesNo
Briefly describe professional help received, who participated, issues worked on, and outcomes:*
NoYesMaybe/Not Sure
Nature and severity of the abuse or violence:*
Please explain the abuse or violence problem and your desired outcome:*
Do you perceive that either you or your partner has withdrawn from the relationship?*
NoYes, I have threatened to leave relationshipYes, partner has threatened to leave relationshipYes, we have both threatened to leave relationshipYes, we are married and I have privately considered divorceYes, we are married and we have discussed divorceYes, we are married and I have threatened divorceYes, we are married and partner has threatened divorceYes, we are married and I have contacted a lawyer about divorceYes, we are married and partner has contacted lawyer about divorce
Please describe any other experiences you have had problems with:
Additional comments or concerns:
*Your signature below indicates that the information you have provided above is truthful.
Date

MonthDayYear
Date
Signature

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Relationship Coaching Intake Form

Welcome to Passionate Awakenings Coaching!

Personal & Contact Information

Emergency Contact Information

Confidentiality and Truthfulness

Relationship Information

Mental Health & Medical History

Relationship Coaching Information