Couples CounselingIntake Form Personal Information Today's Date * MM DD YYYY Name * First Name Last Name Name of Partner Relationship Status • Check all that apply Married Separated Divorced Dating Cohabitating Living together Living apart Length of time in current relationship As you think about the primary reason that brings you here, how would you rate your overall level of concern at this point in time. No concern Little concern Moderate concern Serious concern Very serious concern 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 current level of relationship happiness. Extremely Unhappy Somewhat Unhappy Neutral Somewhat Happy Extremely Happy 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? Yes No If yes, please answer the following: When and by whom? Where and Length of treatment? Problems Treated in previous couples' counseling? What was the outcome? (Check one.) Very successful Somewhat successful Stayed the same Somewhat worse Much worse Have either you or your partner been in individual counseling before? Yes No If so, give a brief summary of concerns that you addressed. Rank order the top three concerns that you have in your relationship with your partner. #1 being the most problematic Additional Information Please use this space to describe any additional information that you feel would be helpful for me to know. Thank you for taking the time to fill out this intake form. Your information will be kept confidential. Feel free to visit the Home page for more information or Contact to reach me with any questions.
