RELATIONSHIP INTAKE FORM

Emergency Assistance: If this is an emergency, call:

Name

First Name

Last Name

Medical History

Do you have concerns about your health or your partner's health?

Yes No

If yes, please explain:

Please list medications/dose that you're currently taking:

Are there any health, hormonal, or aging related changes impacting intimacy?

Partner's Information

Add another emergency contact

YOUR PERSONAL HISTORY

Are any of the above concerns impacting your relationship? If Yes, please describe:

Please describe any traumatic experiences that have impacted your life?

Has there been a history or current concern about physical or sexual abuse in your family or life?

How stressful would your rate your life right now?

Not

Mildly

Moderately

Extremely

EDUCATION AND LEARNING

Highest level of education completed?

Have you ever been diagnosed with a learning disability?

If Yes, please check all that apply:

ADHD

Dyscalculia

Dysgraphia

Dyspraxia

Dyslexia

Comprehension concerns

If you know your learning style, please check all that apply:

I prefer written materials.

I prefer verbal instructions.

I prefer a demonstration before doing.

I need context to understand new information.

EMPLOYMENT

Where are you currently employed?

When did you start this position?

How satisfied are you with your current work/job situation?

Very satisfied

Moderately satisfied

Moderately unhappy

Extremely unhappy

RELATIONSHIP INFORMATION

Name of partner

Length of time in current relationship

Relationship status: check all that apply

Married

Separated

Divorced

Dating

Living together

Living apart

Has either of you threatened separation/divorce as a result of current relationship concerns?

If yes, who?

My partner

Both

If married, have either you or your partner consulted with a lawyer about divorce?

If yes, who?

My partner

Both

Do you perceive that either you or your partner has withdrawn from the relationship?

If yes, who?

My partner

Both

Please list any significant relationships have you had before this relationship:

List any children or dependents and their ages:

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

If yes for either, who, how often and what drugs or alcohol?

Do you ever wish your partner would cut back on his/her drinking or drug use?

Yes

N/A

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

If yes, who, how often and what happened?

For each of the statements below, heck the box that best describes your relationship:

We are staying emotionally connected.

We are becoming emotionally distant.

We are handling job and other stresses effectively.

We are experiencing "spill-over" of other stresses.

We are handling issues or disagreements well.

We are gridlocking on one or more issues.

Our relationship is romantic and passionate.

Our relationship is becoming passionless.

Our sex life is fine.

There are problems in this area.

There has been a recent extra-relationship affair (or I suspect there is one).

This is not an issue.

When disagreements arise, we resolve issues well.

Unpleasant fights have occurred in our relationship.

We agree on basic values, goals, and desired lifestyle.

Differences between us in these areas are arising.

We work well as a team.

We are not working very well as a team right now.

10.

We are handling issues of finances well.

We are having trouble in this area.

11.

We are doing well and having fun together.

We are not having very much fun together.

12.

We are feeling very close in the area of spirituality together.

We are not doing well in that area these days.

STRESSFUL LIFE EVENTS

Please describe any significant or stressful life events you have been experiencing:

If yes, please describe

Beyond the information provided here, what else do you feel is important to know about you and your current situation?

Counseling Goals

What are your current concerns in your relationship?

What do you hope to accomplish through counseling?

What are your biggest strengths as a couple?

What have you done to deal with current concerns/issues?

I want to get an idea of how you're problem-solving. Please provide at least one suggestion of something you could do to improve your relationship.

Communication Consent

Please call or email if you have questions now.

Lastly, by sending this, I consent to the use of digital forms.

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