Couples Intake Form Book An Appointment Couples Counseling Initial Intake Form Thank you for completing this form. Be sure to hit 'Submit' when you are finished.Name* First Last Birth Date* MM slash DD slash YYYY AgeAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneMay we leave a message? Yes No Cell/Other Phone*May we leave a message?* Yes No Email* May we email you?* Yes No Name of Partner* First Last Relationship Status: (check all that apply)* Married Separated Divorced Dating Cohabiting Living Together Living Apart Length of time in current relationship* ChildrenDo you have any children?* Yes No Please list all children (including those not living at home)NameEmailPhone Number General Health and Mental Health InformationHave you previously received any type of mental health services (therapy, psychiatric services, etc.)?* No Yes Previous Therapist/Practitioner Are you currently taking any prescription medication?* No Yes Please list Have you ever been prescribed psychiatric medication?* No Yes Please list and provide dates 1. How would you rate your current physical health?* Poor Unsatisfactory Satisfactory Good Very Good Please list any specific health problems you are currently experiencing* 2. How would you rate your current sleeping habits?* Poor Unsatisfactory Satisfactory Good Very Good Please list any specific sleep problems you are currently experiencing 3. How many times per week do you generally exercise?Please enter a number from 0 to 50.What types of exercise to you participate in 4. Please list any difficulties you experience with your appetite or eating patterns 5. Are you currently experiencing overwhelming sadness, grief or depression?* No Yes If yes, for approximately how long? 6. Have you had any thoughts of harming yourself or others?* No Yes If yes, who have you thought about harming? How do you plan to harm yourself or others? Do you have the means to harm yourself or others? 7. Are you currently experiencing anxiety, panic attacks or have any phobias?* No Yes If yes, when did you begin experiencing this? 8. Are you currently experiencing any chronic pain?* No Yes If yes, please describe 9. Do you drink alcohol more than once a week?* No Yes 10. How often do you engage in recreational drug use?* Daily Weekly Monthly Infrequently Never 11. What significant life changes or stressful events have you experienced recently?* Referred by (if any) 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 conseling?*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 that corresponds with your current feelings about the relationship* 1 (extremely unhappy) 2 3 4 5 6 7 8 9 10 (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 related to any of the above problems?* yes no If yes, when MM slash DD slash YYYY Where By whom Length of treatment Problems treatedWhat was 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 no If so, give a brief summary of concerns that you addressedDo 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 happenedHave 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)*How enjoyable is your sexual relationship?* 1 (extremely unpleasant) 2 3 4 5 6 7 8 9 10 (extremely pleasant) How satisfied are you with the frequency of your sexual relations?* 1 (extremely unsatisfied) 2 3 4 5 6 7 8 9 10 (extremely satisfied) What is your current level of stress (overall)* 1 (no stress) 2 3 4 5 6 7 8 9 10 (highly stressed) What is your current level of stress (in the relationship)* 1 (no stress) 2 3 4 5 6 7 8 9 10 (highly stressed) Rank in order the top three concerns that you have in your relationship with your partner (1 being the most problematic)Rank #1 Rank #2 Rank #3 Please note that you will be asked to talk about your answers in sessions but your partner will not be shown this form.
