Couples Questionnaire and Secure File Transfer

Welcome to Compassionate Edge Counseling. Please complete this form as thoroughly and accurately as possible. The information you provide helps us begin the counseling process, verify your insurance benefits, prepare for your initial appointment, and ensure you are matched with care that best supports your needs and goals. Your privacy is important to us. Any communication by phone, email, or text will not include personal or sensitive details about your counseling. We are committed to providing a confidential, respectful, and supportive experience from your very first interaction with Compassionate Edge Counseling.

Thank you for choosing Compassionate Edge.

We look forward to supporting you on your journey towards meaning change.

Client’s First & Last Name (for the person seeking therapy)

Marital Status (If Applicable)

Married

Divorce

Single

Widowed

Spouse's/Partner's/Parent's Name (If Applicable)

Client's Date of Birth

Client's Gender

Address

City, State, Zip Code

Mobile Phone

Okay to Leave Message

Yes

No

Email

Employment Status

Full-Time

Part-Time

Unemployed

Self-Employed

Are you using EAP benefits?

Yes

No

EAP Company

If using EAP benefits

Authorization #

How did you learn about Compassionate Edge

Do you have a specific therapist or type of therapist you’d like to request? (If not, just leave blank or write “no preference.”)

Preferred Session Type:

In-person

Virtual/Online

No preference

Preferred Days (Select all that apply):

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Preferred Times (Select all that apply):

Morning

Afternoon

Evening

What brought you to couples counseling at this time?

What are the primary concerns you would like to address?

Communication & Conflict

Trust (including infidelity or betrayal)

Emotional Connection & Intimacy

Parenting & Family Relationships

Life Stress and/or Transitions

Premarital Preparation

Other

How long have these concerns been affecting your relationship?

Less than 6 months

6-12 months

1-2 years

More than 2 years

Most of our relatonship

What have you already tried to improve these concerns?

Individual counseling

Couples counseling

Workshops or relationship programs

Church or spiritual guidance

Relationship books or resources

Took a break/separted

Nothing yet

Other

What is one strength in your relationship that gives you hope?

Even if things feel difficult, what is one strength you still see in your relationship?

What do you hope will be different as a result of counseling?

Are you currently living together?

Yes

No

Are either of you currently considering separation or divorce?

No

One partner is considering it

Both partners are considering it

Do you have any concerns about your emotional or physical safety within your relationship?

No

Physical aggression

Threats or intimidation

Emotional or verbal abuse

Controlling behavior

Sexual coercion

Financial control

Fear of partner

Taking psychotropic medications?

Yes

No

Suicidal ideations?

Yes

No

Have you ever attempted suicide?

Yes

No

Prior hospitalization for mental health issues?

Yes

No

Do you (or your partner) have any current or past concerns with gambling?

Yes

No

Do you (or your partner) have any current or past concerns with alcohol or other drug use?

Yes

No

If yes, please provide more details (examples: alcohol, type of drug, how often, how long, and any treatment or support you've received).

General Anxiety Disorder (GAD-7)

Please check the box that best answers the following question - Over the past 2 weeks, how often have you bothered by the following problems?

Feeling nervous, anxious, or on edge?

Not at all

Several days

More than half the days

Nearly every day

Not being able to stop or control worrying?

Not at all

Several days

More than half the days

Nearly every day

Worrying too much about different things?

Not at all

Several days

More than half the days

Nearly every day

Troubling relaxing?

Not at all

Several days

More than half the days

Nearly every day

Being so restless that it's hard to sit still?

Not at all

Several days

More than half the days

Nearly every day

Becoming easily annoyed or irritable?

Not at all

Several days

More than half the days

Nearly every day

Feeling afraid as if something awful might happen?

Not at all

Several days

More than half the days

Nearly every day

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Patient Health Questionnaire (PHQ-9)

Please check the box that best answers the following question - Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things?

Not at all

Several days

More than half the days

Nearly every day

Feeling down, depressed, or hopeless?

Not at all

Several days

More than half the days

Nearly every day

Trouble falling or staying asleep, or sleeping too much?

Not at all

Several days

More than half the days

Nearly every day

Feeling tired or having little energy?

Not at all

Several days

More than half the days

Nearly every day

Poor appetite or overeating?

Not at all

Several days

More than half the days

Nearly every day

Feeling bad about yourself — or that you are a failure or have let yourself or your family down?

Not at all

Several days

More than half the days

Nearly every day

Trouble concentrating on things, such as reading the newspaper or watching television?

Not at all

Several days

More than half the days

Nearly every day

Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual?

Not at all

Several days

More than half the days

Nearly every day

Thoughts that you would be better off dead or of hurting yourself in some way?

Not at all

Several days

More than half the days

Nearly every day

Prior counseling services? When? Where?

Is there anything your therapist should know before your first appointment?

Please upload a copy of your Driver's License and Insurance Card You can add multiple files.

Add file

Please upload a file

Your information will be encrypted.

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