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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 2022
Couples Counseling Initial Intake Form for Healing Broken Hearts
Step
1
of
9
11%
Personal Information
Your Name
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
What type of insurance will you be using? (or if you intend to pay in cash, please write cash)
Home Phone
May we leave a message?
Yes
No
Cell/Work/Other Phone
May we leave a message?
Yes
No
Email
May we leave a message?
Yes
No
Age:
Gender
Date of Birth
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1920
Marital Status
Married
Divorced
Living Together
Living Apart
Separated
Dating
Referred By (if any):
In Case Of Emergency
Name of friend/relative/spouse
First
Last
Relationship to patient
Home phone number
Work phone number
History
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
Yes
No
Are you currently taking any prescription medication?
Yes
No
If yes, please list
General and Mental Health Information
How would you rate your current physical health?
Poor
Unsatisfactory
Satisfactory
Good
Very good
Please describe any specific health problems you are currently experiencing
How would you rate your current sleeping habits
Poor
Unsatisfactory
Satisfactory
Good
Very good
Please describe any specific sleep problems you are currently experiencing
Please describe any difficulties you experience with your appetite or eating problems
If yes, for approximately how long?
Are you currently experiencing anxiety, panic attacks or have any phobias?
Yes
No
If yes, when did you begin experiencing this?
Are you currently experiencing any chronic pain?
Yes
No
If yes, please describe
Do you drink alcohol more than once a week?
Yes
No
How often do you engage in recreational drug use?
Daily
Weekly
Monthly
Infrequently
Never
Are you currently in a romantic relationship?
Yes
No
If yes, for how long?
On a scale of 1-10, how would you rate your relationship?
What significant life changes or stressful events have you experienced recently?
Additional Information
Are you currently employed?
Yes
No
If yes, what is your current employment situation?
Do you enjoy your work? Is there anything stressful about your current work?
Do you consider yourself to be spiritual or religious?
Yes
No
If yes, describe your faith or belief
What do you consider to be some of your strengths?
What do you consider to be some of your weakness?
Couple Information
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 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 extremely unhappy, 10 being extremely happy)
What is your current level of stress in the relationship?
(1 being extremely unhappy, 10 being extremely happy)
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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