Couple's Counseling Intake Form

Trinity Psych Wellness

Couples Counseling Initial Intake

Conatct Information

Your First Name

Your Last Name

Your Email

Date of Birth (day/month/year)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Your Phone/Cell

Date / Time

Partner's First Name

Partner''s Last Name

Relationship Status - select one

Dating

Cohabitating

Married

Living apart

Separated

Divorced

Length of time in current relationship:

Emergency Contact Person:

As you think about the primary reason that brings you here, how would you rate its CONCERN at this point in time?

no concern

little concern

moderate concern

serious concern

very serious concern

As you think about the primary reason that brings you here, how would you rate its FREQUENCY at this point in time?

no occurrence

occurs rarely

occurs sometimes

occurs frequently

occurs nearly always

What do you hope to accomplish through counseling?

What have you already done to deal with the difficulties?

What are your biggest strengths as a couple?

Please rate your relationship's current level of happiness by selecting the number that corresponds with your current feelings about the relationship.

extremely unhappy extremely happy
0	1	2	3	4	5	6	7	8	9	10

Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does.

Have you received prior couples counseling related to any of the above problems?

Yes

If yes, then when

If yes, where

If yes, with whom

Problems treated:

Rate the outcome

Very successful

Somewhat successful

Stayed the same

Somewhat worse

Much worse

Have either you or your partner been in individual counseling before?

Yes

If yes, give a brief summary of concerns that you addressed.

Do either you or your partner drink alcohol to intoxication or take drugs to intoxication?

Yes

If yes for either, who, how often and what drug(s) or alcohol?

Have either you or your partner struck, physically restrained, used violence against or injured the other person?

Yes

If yes for either, who, how often, and what happened.

Has either of you threatened to separate or divorce (if married) as a result of the current relationship problems?

Yes

If yes, who threatened to separate or divorce?

Self

Partner

Both of us

If married, have either you or your partner consulted with a lawyer about divorce?

Yes

If yes, who consulted with a lawyer about divorce?

Self

Partner

Both of us

Do you perceive that either you or your partner has withdrawn from the relationship?

Yes

If yes, which of you has withdrawn?

Self

Partner

Both of us

How frequently have you had sexual relationships during the last month?

How enjoyable is your sexual relationship? (Select one)

extremely unpleasant extremely pleasant
0	1	2	3	4	5	6	7	8	9	10

How satisfied are you with the frequency of your sexual relations? (Select one)

extremely unpleasant extremely pleasant
0	1	2	3	4	5	6	7	8	9	10

What is your current level of stress (overall)? (Select one)

extremely unpleasant extremely pleasant
0	1	2	3	4	5	6	7	8	9	10

What is your current level of stress (in the relationship)? (Select one)

extremely unpleasant extremely pleasant
0	1	2	3	4	5	6	7	8	9	10

Rank order the top three concerns you have in your relationship with your partner (1 being the most problematic):

Tell me about your relationship over time and level of satisfaction beginning with when you met your partner. Note pivotal / significant events in your relationship within a time frame.

Thank You

Please note that you will be asked to talk about your answers in sessions, but your partner will not be shown this form.

Please complete this form to the best of your ability.

Trinity Psych Wellness

Conatct Information

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