CONFIDENTIAL Couples Counseling

Intake Form

Date: ______

Name: ______

Partner’s Name: ______

Home phone:Work phone:

OK to leave message? ___yes ___noOK to leave message? ___yes ___no

Mailing Address:

City/State/Zip:

Emergency Contact:

Name Relationship Phone

Source of Income: Occupation:Employer:

Relationship Status
(check all that apply)
□ Dating
□In a committed relationship
□ Civil Union □ Married
□ Separated □ Divorced
□ Living together □ Living apart
□ Widowed
□ Other / Current Employment
□ Full-time
□ Part-time
□ Homemaker
□ Unemployed
□ Full-time student
□ Part-time student
□ Retired / Annual Household Income
□ $0-10,000
□ $10,001-20,000
□ $20,001-40,000
□ $40,001-75,000
□ $75,001-100,000
□ $100,001+

Length of time in current relationship: ______

Children (including, biological, adopted, foster, step):

Name Sex Age Type Custody

______□ Yes □ No

______□ Yes □ No

______□ Yes □ No

______□ Yes □ No

______□ Yes □ No

Please check any of the reasons listed below that resulted in your request for counseling:

□ Depression or anxiety
□ Alcohol/drug abuse
□ Relationship problems
□ Communication difficulties
□ Psychological evaluation
□ Improve sexual relations
□ Child/parent conflict
□ Divorce counseling
□ Pre-marital counseling / □ Thinking of harming self or others
□ Learning difficulties
□ School problems
□ Family counseling
□ Individual counseling
□ Difficulty with loss or death
□ Relationship enhancement
□ Abuse (physical/mental)
□ Other

As you think about the primary reason that brings you here, how would you rate its frequency

and your overall level of concern at this point in time?

Concern
□ No concern
□ Little concern
□ Moderate concern
□ Serious concern
□ Very serious concern / Frequency
□ No occurrence
□ Occurs rarely
□ Occurs sometimes
□ Occurs frequently
□ Occurs nearly always

Which Areas Would You Like to Focus On:

Making Your Relationship Work:
  • Emotional Distance/Lack of Intimacy
  • Anger/Arguing
  • Name Calling, Sniping, Belittling, Threats, Blaming
  • Unexpressed Feelings
  • Feeling of Deprivation
  • Unresolved or Repeating Cycles of Conflict
  • Unexpressed Needs
  • Conflicting Concepts of Partnership
  • Feelings of Unfairness. Inequity
  • Lack of Time/Growing Apart
  • Misunderstanding
  • Unmet Expectations
  • Not Feeling Heard
  • Guilt
  • Negative Assumptions about Partner
  • Feeling of Going in Circles
  • Feeling Hurt
  • Discouragement/ Depression
  • Negativity
  • Disenchantment
  • How to Get Past an Affair
DBT (Dialectical Behavioral Skills for a High Conflict Couple)
  • Understanding Emotions in Relationships
  • Accepting Yourself and Your Partner
  • How To Stop Making Things Worse
  • Being “Together” When You Are Together
  • Reactivating Your Relationship
  • Accurate Expression
  • Validating Responses: What to Validate and Why
  • Validating Responses: How to Validate Your Partner
  • Recovering from Invalidation
  • Managing Problems and Negotiating Solutions
  • Transforming Conflict into Closeness
Learning the Five Languages of Love
  • How to Understand and Respond to Each Other’s Needs (Love Languages: Words of Affirmation, Quality Time, Receiving Gifts, Acts of Service, Physical Touch)

Please draw a graph indicating your level of relationship satisfaction beginning with when you met

your partner. Note pivotal events in your relationship.

Complete satisfaction

No satisfaction Relationship over time

Please rate your current level of relationship happiness by circling the number which corresponds with

your current feelings about the relationship.

0 1 2 3 4 5 6

Extemely Fairly A Little Happy Very Extremely Perfect

Unhappy Unhappy Unhappy Happy Happy

Please make at least one suggestion as to something you could personally do to improve the

relationship regardless of what your partner does.

______

______

Have you ever been to counseling as a result of problems with this relationship prior to

today? ______If so, what was the outcome of that counseling?

______

______

______

Have either you or your partner been in individual counseling before? ______If so, give a brief summary.______

______

Do you feel that either you or your partner have a problem withalcohol or drugs?______

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

Has either you or your partner struck, physically restrained, used violence against or injuredthe other person? ______If yes for either, who, how often and what happened. ______

______

Has either of you threatened to separate or divorce as a result of the current relationship problems?______

Have either you or your partner consulted with a lawyer about divorce? ______

Do you perceive that either you or your partner has withdrawn from the relationship?______If yes, which of you has withdrawn? ______

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

How enjoyable is your sexual relationship? (Circle one)

Terrible More unpleasant Not pleasant, More pleasant Great

than pleasant not unpleasant than unpleasant

Basic Health: (Circle one) excellent good fair poor

Why are you pursuing counseling at this time?

What would you like to see happen as a result of counseling?

What do you hope to gain from today’s consultation?

Is there anything else you wish to add?______

______

Fee Agreement: $_______

Client Signature:______Date:_________

Resilient Journeys, PLLC-220 3rd Ave, W. Unit A; POB 1426, Hendersonville, NC 28793

828-376-0055; Fax-828-376-0155