Couple's Counseling Intake Form

Current Patient OR New Patient

Please complete this form to the best of your ability.

Couples Counseling Initial 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

Emergency Contact Person:

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.

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.

About

Trinity Psych Wellness is an online private practice to maximize the convenience and care for our patients and their well-being.

Terms & Conditions

Services

• Client-Centered & Couple’s Therapy
• Genetic Testing
• Medication Management
• Treatment Across Life-Span (Ages 4+)

Hours

Monday-Thursday: 9:am – 6:pm MST. We will do our best to accommodate various schedules, including outside hours. Please contact for any questions.

Telephone + SMS (623) 343-7213
Fax (623) 292-2285

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