Couples Counseling Initial Intake Form
Please note that while you will be asked to talk about your answers in sessions, your partner will not be shown this form.
Name: ____________________________________________
Date __________
Phone:________________________________
May I leave a message? Y / N
Is it acceptable to email you? If so, email address:_______________________________________________
Relationship Status:
(check all that apply)
Married
Living Together
Divorced
Separated
Living apart
Dating
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 by circling the number that corresponds with your current
feelings about the relationship.
1
2
3
4
5
6
7
8
9
10
(extremely unhappy)
(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, With whom:________________________________________________________
Where: _____________________
Length of treatment_________________
Outcome: __________________________________________________________
___________________________________________________________________