Email

Occupation

Education

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?

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?

Couples Intake Form

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