Clone of Relationship Therapy Questionnaire

Is couples therapy with me right for you?

Not every couple or relationship is suited to the way I work, so I offer a free, 3-minute suitability check before you decide whether to complete a full application.

You’ll be asked a small number of questions about your relationship and current circumstances. There are no lengthy written answers, and it’s designed to be quick and easy to complete on your phone.

Once you’ve completed the check, you’ll receive an email letting you know whether it may be appropriate to proceed to the full couples therapy application.

Additional information can be provided at a later stage if your application proceeds.

Completion of the check or 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.

Name* This field is required.

First Name

Last Name

Email* This field is required.

example@example.com

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

YESNO

Are you having any thoughts of self-harm?* This field is required.

YESNO

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

YESNO

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

YESNO

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

YESNO

Are you currently experiencing a significant mental health difficulty that is substantially affecting your daily functioning or the relationship?* This field is required.

YESNO

Is your partner currently experiencing a significant mental health difficulty that is substantially affecting their daily functioning or the relationship?* 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

Your partner has threatened, suggested, implied or otherwise made you worry that they may harm themselves if the relationship were to end

None of the above

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 submit your suitability check?* This field is required.

YESNO

Clone of Relationship Therapy Questionnaire