Couples Consent and Intake Form

COUPLES CONSENT FORM

Successful relationships are based on clear policies and procedures, so please review the following carefully and thoroughly. If you have any questions, please feel free to ask me at any time.

CONSISTENCY/FREQUENCY

Couples therapy is more effective when both individuals in the partnership attend appointments in a consistent manner. I will generally meet with you on a weekly basis for approximately 45-60, which is recommended for effective progress and growth. The frequency of sessions/length of session time may be evaluated during times of crisis, as well as when it is mutually decided and clinically relevant to either increase or decrease the frequency/length of your session. I may also choose to meet with each partner of the couple individually for therapeutic purposes. I will communicate my intention and rationale to you prior to scheduling individual sessions.

ATTENDANCE/CANCELLATIONS

The established appointment time is set aside for a particular couple. It is expected that you will be prompt for your appointment. If you or your partner arrives late for your appointment, the session will only start with both individuals present, and the session will still end at the regularly scheduled time.

Sometimes emergencies come up. If I need to cancel or change an appointment time, you will receive more than 24 hours’ notice, as I know that you will have reserved the time for the appointment.

Likewise, it is expected that you and/or your partner will give me more than 24 hours’ notice if you must cancel the appointment. If, for any reason, you and/or your partner cannot let me know more than 24 hours in advance you will be charged the late cancellation fee. It is recommended for consistency that you attempt to reschedule the appointment within the same week.

If, for whatever reason, only one partner shows up to the session, for the sake of the neutrality and symmetry of the therapy, I will not conduct an individual session. I apologize in advance for the inconvenience, but it is important that I, as your therapist, maintain neutrality and objectiveness in the couples’ counseling relationship. It is, nonetheless, expected that the full session fee for the session will be paid.

SHARED INFORMATION

If you or your partner shares information with me in private, I will encourage you to share this information voluntarily to your partner in our session. If you do not share this information, I will need to share this information in order to preserve my neutral position in our therapeutic relationship.

CONFIDENTIALITY

I will adhere to the ethical and legal requirements of confidentiality as stated on your individual informed consent form. I cannot, however, ensure that you and your partner will maintain confidentiality about your therapeutic experience including content discussed within the couples’ counseling session.

The signatures here show that we each have read, discussed, understand, and agree to abide by the points presented above as indicated by my signature below.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Client Name

Client Signature

Date

Questionnaire

* indicates a required field

Prior to your first appointment, please answer all questions below. Do not spend too much time on any question.

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 frequently does it occur?

No occurrence Occurs rarely Occurs sometimes Occurs frequently Occurs nearly always

As you think about the primary reason that brings you here, how would you rate your overall concern about it?

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?

Have you received prior couples counseling related to any of the above problems?

Yes No

Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does

If you have received prior couples counseling, when did this occur? (If you have not received prior couples counseling, please type N/A.)

If you have received prior couples counseling, where did this occur? (If you have not received prior couples counseling, please type N/A.)

If you have received prior couples counseling, who counseled you? (If you have not received prior couples counseling, please type N/A.)

If you have received prior couples counseling, what was the length of treatment? (If you have not received prior couples counseling, please type N/A.)

If you have received prior couples counseling, what were the problems that were treated? (If you have not received prior couples counseling, please type N/A.)

Have either you or your partner been in individual counseling before?

Yes No

Do either you or your partner drink alcohol to intoxication or take drugs to intoxication?

Yes No

If you have received prior couples counseling, what was the outcome? (If you have not received prior couples counseling, please type N/A.)

Much worse Somewhat worse Stayed the same Somewhat successful Very successful N/A

If married, has either of you threatened to separate or divorce as a result of the current relationship problems? If not married, please answer N/A.

Yes No N/A

Have either you or your partner struck, physically restrained, used violence against, or injured the other person?

Yes No

Do you perceive that either you or your partner has withdrawn from the relationship?

Yes No

If married, have either you or your partner consulted with a lawyer about divorce? If not married, please answer N/A.

Yes No N/A

How frequently have you had sexual relations during the last month?

List your top three concerns that you have in your relationship with your partner (1 being the most problematic)

Thank you for completing this. Please note that you will be asked to talk about your answers in appointments, but your partner will not be shown this form.

Your information will be encrypted.