Couples Counseling - Intake Form

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Couples Counseling Initial Intake Form

Name of Initiating Partner

Today’s Date

Name of Partner

Relationship Status: (check all that apply)

Married Separated Divorced Dating Cohabitating Living together Living apart

Length of Time in Current Relationship:

Number of Children Residing in the Home

Ages of Children

Are you a Blended Family

As you think about the primary reason that brings you here, how would you rate its frequency and your overall level of concern at this point in time?

Concern

No concern

Little concern

Moderate concern

Serious concern

Very serious concern

Frequency

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 Bbiggest Strengths as a Couple?

Please rate your current level of relationship happiness by circling the number that corresponds with your current feelings about the relationship

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

Yes No

If yes, When

Where

By Whom

Length of Treatment

Problems Treated

What was the Outcome (check one)?

Very Successful Somewhat Successful Stayed the Same Somewhat Worse Much Worse

Whose Idea was it to come to Therapy?

Was there a Prompting Event that led someone to make this Call? (Why seek help now?)

Have Either you or your Partner been in Individual Counseling Before?

Yes No

If so, 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 No

If yes for Either, Who, How often and what Drugs or Alcohol?

Have Either you or your Partner Struck, Physically Restrained, used Violence Against or Injured the other Person?

Yes No

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 No

If yes, Who? Me

Partner

Both of us

If Married, have Either you or your partner consulted with a Lawyer About Divorce?

Yes No

If yes, Who? Me

Partner

Both of us

Do you Perceive that Either you or your Partner has withdrawn from the Relationship?

Yes No

If yes, Which of you has withdrawn? Me

Partner

Both of us

How Frequently have you had Sexual relations during the last Month? Times

Have you or your Partner ever Emotionally or Physically Cheated on each other?

Yes No Unsure

If yes, Who? Me

Partner

Both of us

How Enjoyable is your Sexual Relationship? (Circle one)

How Satisfied are you with the Frequency of your Sexual Relations? (Circle one)

What is your Current Level of Stress (overall)? (Circle one)

What is your Current Level of Stress (in the Relationship)? (Circle one)

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

Is there Anything else that you would like to Mention?

FAMILY MENTAL HEALTH HISTORY:
In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.).

Alcohol/Substance Abuse

Yes No

Anxiety

Yes No

Depression

Yes No

Domestic Violence

Yes No

Eating Disorders

Yes No

Obesity

Yes No

Obsessive Compulsive Behavior

Yes No

Schizophrenia

Yes No

Suicide Attempts

Yes No

First Name *

Last Name *

Email *

Phone *