COUPLES - Confidential Questionnaire

Date*

Date

Client 1 Full Name:

Client 2 Full Name:

Primary Address

Street Address

Street Address Line 2

Town / CityCounty / State / Province

Post Code / Zip CodeCountry

Client 1 E-mail

example@example.com

Client 2 E-mail

example@example.com

Client 1 Mobile:*

Client 2 Mobile:*

Current Marital / Relationship Status of Couple:

How long have you been together?

How long have you been separated, to the nearest month?

Do you have children together?

YESNO

How many children do you have?

Details of your family:

More information on:

Client 1

Date of Birth:*

Client

Occupation / Work Status:

Client 1

Sexuality

Client 1

How would you describe yourself (in a few sentences):

Client 1

More information on:

Client 2

Date of Birth:*

Client 2

Occupation / Work Status:

Client 2

Sexuality

Client 2

How would you describe yourself (in a few sentences):

Client 2

How did you hearing about our coaching services?

Please give a brief outline of why you are seeking couples coaching:*

Please complete this section objectively

Have you previously participated in any kind of couples coaching/relationship counselling/Relate etc.?

YESNO

You answered ‘YES’ to the above, what worked and what didn’t in your opinion during your previous experiences in trying to resolve your issues together?

We would consider couples coaching to have been a success if we can (complete below):*

The biggest obstacles to this being a success are (complete below):*

Do you have any questions you wish to ask ahead of our session together?

YESNO

Questions we have ahead of, or to be addressed during our session(s) together: *

- We hereby confirm that, to the best of my knowledge the information I have given is correct.

- We are aware that I am entering a working coaching relationship where my commitment and collaboration is vital to attaining a successful outcome. This includes completing tasks and exercises assigned and of which I cannot provide any tangible or reasonable objections.

- We acknowledge that all client and coaching content is strictly confidential.

- No audio/video recording of the session may be allowed. I can however, request a video recording be made of the session for mutual protection and held securely for future reference (the exception to this being if a media waiver form has been signed in order that sessions can be used for training purposes).

- We are happy to pay in advance to secure the initial and subsequent appointments, with the understanding that any questions raised in the relevant section within the above questionnaire will have been responded to in writing prior to the first consultation.

By signing the below we acknowledge and agree to ALL OF THE ABOVE

Client 1 Signature*

Client 2 Signature*

COUPLES QUESTIONNAIRE

CLIENT DETAILS

Further Information

Relationship Goals - What are you aiming for?