Marital Intake Form

Name

First NameLast Name

Date of Birth

MonthDayYear

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Gender

Ethnicity

Level of Education

My relationship with my partner is more important to me than almost anything else in my life

I want this relationship to stay strong no matter what rough times we may encounter.

If retired, what was your occupation?

Use ‘N/A’ if this field doesn’t apply to you.

What is your current occupation?

What is your spouse's occupation?

What is your religious affiliation?

Other

All things considered, how central is your faith to your day to day life?

How long have you been married to your spouse?

How long were you and your spouse engaged?

Did you live together before you were married? If yes, how long?

Have you been previously married? If yes, how many times?

Have you ever been widowed? If yes, when?

How many children do you have with your spouse?

Use ‘N/A’ if this field doesn’t apply to you.

How many children do you have with your previous spouse?

Use ‘N/A’ if this field doesn’t apply to you.

Please list the ages and genders of your children. (Please note if they are step children and whether or not they live with you)

Use ‘N/A’ if this field doesn’t apply to you.0/800

Total number of people living in your home

Please mark the statement that best describes your living situation with your spouse.

On a scale of 1 to 5, how committed are you to your marriage?

In your own words, describe the problems and issues that prompted you to seek therapy.

0/800

Have you attended therapy/counseling before? If yes, how many sessions?

Check the type of therapy/counseling you recieved

How satisfied were you with the therapy/counseling you recieved?

Please check any topic that you believe is an issue in your relationship

Please provide the following information concerning your parents.

Father's Name

Mother's Name

Father's Occupation

Mother's Occupation

Father's Age (If deceased, please include date of death)

Mother's Age (If deceased, please include date of death)

Describe your relationship with your father.

0/800

Describe your relationship with your mother.

0/800

List your siblings in birth order. Name - Age - Living? - Occupation

Use ‘N/A’ if this field doesn’t apply to you.0/800

Describe how you were disciplined growing up.

0/800

In your own words, describe your parents' marital relationship.

0/800

Were you raised in a step or blended family? If yes, how many years?

In your estimation, who is more interested in coming to therapy/counseling?

How hopeful are you about achieving a satisfying marriage through therapy/counseling?

Do you or your spouse have any chronic health conditions or disabilities? If yes, please describe the chronic conditions.

0/800

Please list the medications you are currently taking.

Use ‘N/A’ if this field doesn’t apply to you.0/800

Has your spouse or close friend ever indicated that you have a problem with alcohol or drugs?

Does your spouse have a problem with alcohol or drugs?

Do you use alcohol or drugs on a weekly basis? If yes, indicate what you use and how much on a daily/weekly basis.

0/800

Did one or both of your parents use alcohol or drugs?

In your marriage, what is your goal or hope at this time?

0/800

What initially attracted you to your partner?

0/800

In your couple history, when do you believe the relationship was the most satisfying? Why?

0/800

How did you decide to get married?

0/800

Describe how you believe problems developed in the marital relationship and what you have tried to correct the problems.

0/800

How are you and your spouse similar?

0/800

How are you and your spouse different?

0/800

What activities do you and your spouse engage in together?

0/800

What activities do you engage in by yourself?

0/800

What would your spouse say is the main problem in the marriage?

0/800

Please give us any information that you feel is pertinent in preparation for counseling.

0/800