Client Assessment

Client Intake / Assessment

Please complete this assessment using the same wording and section order as the source document. Unless otherwise indicated in the document, fields are optional.
Basic Couple Information
Full Name

First NameLast Name
Partner’s Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
City/State
Ages
Occupations
How long have you been together?
How long have you been married?
Do you have children? If yes, please list their ages.
Current Relationship Status
Current status

Other
If Other (current status), please describe
Reason for Seeking Coaching
What prompted you to seek coaching now?
Why are you seeking coaching?

Other
If other, please describe
What do you hope will be different six months from now?
What is your biggest concern about your relationship?
What is your second biggest concern about your relationship?
What is your third biggest concern about your relationship?
Motivation & Readiness
I want this relationship to improve

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1 is Strongly disagree, 10 is Strongly agree
My partner wants this relationship to improve

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1 is Strongly disagree, 10 is Strongly agree
I believe change is possible

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1 is Strongly disagree, 10 is Strongly agree
I am willing to change my own behavior

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1 is Strongly disagree, 10 is Strongly agree
Relationship Assessment Scales
I feel emotionally safe with my partner.

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1 is Strongly Disagree, 10 is Strongly Agree
I can express my feelings honestly without fear of judgment or retaliation.

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1 is Strongly Disagree, 10 is Strongly Agree
I feel accepted and respected in this relationship.

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1 is Strongly Disagree, 10 is Strongly Agree
We communicate openly and clearly with each other.

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1 is Strongly Disagree, 10 is Strongly Agree
We listen to each other without interrupting or becoming defensive.

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1 is Strongly Disagree, 10 is Strongly Agree
We are able to resolve conflicts in a constructive way.

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1 is Strongly Disagree, 10 is Strongly Agree
I trust my partner.

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1 is Strongly Disagree, 10 is Strongly Agree
My partner trusts me.

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1 is Strongly Disagree, 10 is Strongly Agree
We are honest with each other.

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1 is Strongly Disagree, 10 is Strongly Agree
We enjoy spending time together as friends.

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1 is Strongly Disagree, 10 is Strongly Agree
We share laughter, affection, and companionship.

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1 is Strongly Disagree, 10 is Strongly Agree
We feel emotionally connected.

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1 is Strongly Disagree, 10 is Strongly Agree
We are satisfied with our physical intimacy.

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1 is Strongly Disagree, 10 is Strongly Agree
We are comfortable discussing our intimate needs and desires.

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1 is Strongly Disagree, 10 is Strongly Agree
Our physical affection feels mutual and satisfying.

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1 is Strongly Disagree, 10 is Strongly Agree
We share similar goals and values for the future.

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1 is Strongly Disagree, 10 is Strongly Agree
We make plans together for our relationship and family life.

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1 is Strongly Disagree, 10 is Strongly Agree
We feel aligned about major life decisions.

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1 is Strongly Disagree, 10 is Strongly Agree
I take responsibility for my actions in this relationship.

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1 is Strongly Disagree, 10 is Strongly Agree
I am willing to grow and change where needed.

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1 is Strongly Disagree, 10 is Strongly Agree
Strengths, Hopes, and Fears
What is one thing your partner does well?
What is one area where you would like to improve?
If your relationship could change in one meaningful way, what would it be?
What is keeping you invested in this relationship?
What fears do you have about your future together?
Commitment & Hope
How committed are you to improving this relationship?

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1 is Not at all committed, 10 is Fully committed
How willing are you to examine your own behaviors?

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1 is Not at all willing, 10 is Fully willing
How hopeful are you that meaningful change is possible?

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1 is Not at all hopeful, 10 is Very hopeful
Current Challenges & Desired Outcomes
What is the biggest challenge your relationship is facing today?
What worries you most about your future together?
If coaching is successful, what would your relationship look like six months from now?
Previous Help & Impact
Previous Help: Have you tried
Previous Help: What helped?
Coaching Goals
Top Outcome 1
Top Outcome 2
Top Outcome 3
Final Notes for Coach
Is there anything you would like me to know before our first session?
What would make this coaching experience successful for you?
Physiological & Environmental Factors: In the interest of achieving total clarity during our intensive, are there any substances (Alcohol, Marijuana, Prescription, or Recreational Drugs) regularly used by you or your partner that may impact your mood, communication, or ability to maintain a regulated nervous system?
Are you currently involved in an active investigation or litigation with the Florida Department of Children and Families?
Should be Empty:

Client Intake / Assessment

Basic Couple Information

Current Relationship Status

Reason for Seeking Coaching

Motivation & Readiness

Relationship Assessment Scales

Strengths, Hopes, and Fears

Commitment & Hope

Current Challenges & Desired Outcomes

Previous Help & Impact

Coaching Goals

Final Notes for Coach