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Menu
Home
Learn More
About Us
Testimonials
Services
Adolescent Life Coaching
Family Life Coaching
Individual Life Coaching
Marriage Life Coaching
Forms
Contact Us
Couples Counseling Initial Intake Form
Initial intake form for couples counseling at Healing Broken Hearts
Step
1
of
5
20%
Name
*
First
Last
May I leave a message?
*
Yes
No
Phone
May I leave an email?
*
Yes
No
Email
Relationship Status
*
(check all that apply)
Married
Living Together
Separated
Divorced
Living Apart
Dating
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?
Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does.
Please rate your current level of relationship happiness by sliding to the number that corresponds with your current feelings about the relationship.
(1 being extremely unhappy, 10 being extremely happy)
Have you received prior couples counseling related to any of the above problems?
*
Yes
No
Have either of you been in individual counseling before?
Yes
No
Do either you or your partner drink alcohol or take drugs to intoxication?
Yes
No
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
No
Have either you or your partner struck, physically restrained, used violence against or injured the other person?
Yes
No
Who, how often, and what happened?
Have either of you threatened to separate or divorce (if married) as a result of the current relationship problems?
Yes, I have
Yes, my partner has
Yes, both of us have
No, neither of us have
If married, have either you or your partner consulted with a lawyer about divorce?
Yes, I have
Yes, my partner has
Yes, both of us have
No, neither of us have
Do you perceive that either you or your partner has withdrawn from the relationship?
Yes, I have
Yes, my partner has
Yes, both of us have
No, neither of us have
How enjoyable is your sexual relationship?
(1 being extremely unhappy, 10 being extremely happy)
How satisfied are you with the frequency of your sexual relations?
(1 being extremely unhappy, 10 being extremely happy)
What is your current level of stress overall?
(1 being no stress, 10 being high stress)
What is your current level of stress in the relationship?
(1 being no stress, 10 being high stress)
Rank the order of the top three concerns you have in your relationship with your partner. (1 being the most problematic)
1.
2.
3.
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