COUPLES INTAKE FORM Please complete the SECURE on-line form below. Please enable JavaScript in your browser to complete this form.NameDate DateName of partnerRelationship Status:MarriedSeparatedDivorcedCohabitatingLiving togetherLiving apartLength of time in current relationshipAs you think about the primary reason that brings you here, how would you rate its frequency and your overall llbevel of concern at this point in time?No concernLittle concernModerate concernSerious concernVery serious concernNo occurrenceOccurs rarelyOccurs sometimesOccurs frequentlyOccurs nearly alwaysWhat do you hope to accomplish through counseling?What have you already done to deal with difficulties?What are your biggest strengths as a couple?Please make at least one suggestion as to something you could personally do to lmprove the relationship Wregardless of what your partner docs.Have you received prior couples counseling related to any of the above problems?YesNoWhat was the outcome(check one)?Very successfulSomewhat successfulStayed the sameSomewhat worseMuch worseHave either you or your partner been in individual counseling before?YesNoIf 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?YesNoIf yes for either,‘ who, how ofien and what drugs or alcohol?Have either you or your partner struck, physically restrained, used violence against or injured the other person?YesNoIf yes for either, who, how often and what happened.Rank order ‘the top three concerns that you have in your relationship with your partner (1 being the most problerrnatic):Submit
