Couples Intake Form Name * First Name Last Name Birth Date: * MM DD YYYY Occupation: Education: Who were you referred by?: Current Relationship Status (Please check all that apply): Living Together Dating Engaged Married Separated Monogamous Polyamorous Open Other If you checked "other", please specify RELATIONSHIP HISTORY How long have you known your partner? How long have you been in a relationship with your partner? How long have you been experiencing relationship difficulties with your partner? Have you ever been married in the past? If so, were you divorced or widowed? CURRENT HOME ENVIRONMENT Do you have children and/or step-children? If so, how many and what are their living arrangements? Do you currently have any relatives or friends living in the home with you? If so, who? I am attending counseling because (Please check all that apply): It is important to my partner It is important to me Family / friends encouraged my partner and I I want to improve my relationship with my partner The next step is separation The next step is divorce Other Kindly specify if you checked other Desired Outcomes for Self (Please check all that apply): Get more of my needs met in my relationship Be more patient with my partner Communicate effectively with my partner Be supportive of my partner Express my anger without hurting my partner Feel more secure in my relationship I Feel better about myself Be less critical of my partner Decrease feelings of jealousy Other Kindly specify if you checked other Desired Outcomes for Couple (Please check all that apply): Participate in new activities as a couple Laugh and enjoy each other as a couple Take an interest in each other’s hobbies Show affection with each other Verbalize thoughts & feelings effectively Spend more time together Learn how to disagree in a calm way Be honest with each other about our feelings Improve sexual relationship Increase the level of trust in our relationship Improve parenting of children Work together as a team Other Kindly specify if you checked other Areas of Concern (Please check all that apply): Abuse/Domestic Violence currently Abuse/Domestic Violence in the past Children Communication styles and/or patterns (verbal/nonverbal) Critical partner Difference in work schedule Elder care concerns/stressors Expression of love /affection Extended family/in-law relationships Extramarital relations/affair/infidelity Financial stressors that lead to relationship conflict Household responsibility/roles Infertility Lack of trust Lack of support from partner for career, interests, hobbies Pregnancy Loss Intimacy/sexual concerns Medical Diagnosis of partner or self Medical diagnosis of child Mental health concerns Physical care of partner Previous marriage/step-child(ren) relationship concerns Religion/spirituality/culture Recent legal problems Recent loss of loved one or friend Substance use Suicidal thoughts Homicidal thoughts Time spent together Work/career concerns Other Kindly specify if you checked other How has your life been impacted by your relational problems? (Please check all that apply): Sleeping problem Eating habits have changed Affecting my job Feeling irritable Feeling fearful Feeling angry Feeling sad Feeling lonely Difficulty parenting Increased fighting with friends or family Financial trouble Low self-esteem Less time with family and friends Other Kindly specify if you checked other Have there been any major changes in your life in the past 6 months? (Check all that apply): Death of a friend or family member Move Friend or family moved Friend or family moved into home Pregnancy Birth of a child Pregnancy Loss Adoption Loss of job Change of job Went back to school Diagnosis of medical condition Other Kindly specify if you checked other Have you ever attended couples counseling in the past? If so, when and for what concerns? Have you ever sought counseling for yourself? If so, when and for what concerns? Have you ever been diagnosed with a mental or emotional disorder? If so, when and what?Are you currently on any medications? If so, please list the medications and the conditions they treat: Is there any other information that will be helpful for us to know about you and / or your relationship? The information contained herein is complete and truthful to the best of my/our ability. I agree I do not agree Thank you!
