Name
*
First Name
Last Name
Email Address
*
Name of Partner
Relationship Status
Married
Seperated
Divorced
Dating
Cohabitating
Living together
Living Apart
As you think about the primary reason that brings you here, how would you rate your overall concern at this point in time?
No concern
Little concern
Moderate concern
Serious concern
Very serious concern
As you think about the primary reason that brings you here, how would you rate it's frequency at this point in time? ( How often does what you are concerned about occur?)
No occurrence
Occurs rarely
Occurs sometimes
Occurs frequently
Occurs nearly always
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 rate your current level of relationship happiness by circling the number that corresponds with your current feelings about the relationship
1 ( extremely unhappy )
2
3
4
5
6
7
8
9
10 ( extremely happy)
If you received prior couples counseling what was the length of treatment & the problems treated?
What was the outcome ( check one)
Very successful
Somewhat successful
Stayed the same
Somewhat worse
Much worse
Have either you or your partner been in INDIVIDUAL counseling before?
Yes
No
If yes, give a brief summary of concerns that you addressed.
This is the end of the short intake form, only proceed if directed to do so. Thank you for your time. I look forward to meeting with you on our initial session. Natalie Teeters, M.S., Registered Psychotherapist.
Do either you or your partner drink alcohol to intoxication or take drugs to intoxication? If yes for either, who, how often and what drugs or alcohol?.
Have either you or your partner struck physically restrained, used violence against or injured the other person? If yes for either, who, how often and what happened?
Has either of you threatened to seperate or divorce ( if married ) as a result of the current relationship problems?
No
Yes, me
Yes, partner
Yes, both of us
If married, have either you or your partner consulted with a lawyer about divorce?
No
Yes, me
Yes, partner
Yes, both of us
Do you perceive that either you or your partner has withdrawn from the relationship?
No
Yes, me
Yes, partner
Yes, both of us
How frequently have you had sexual relations during the last month?_____ times?
How enjoyable is your sexual relationship?
1 ( extremely unpleasant )
2
3
4
5
6
7
8
9
10 ( extremely pleasant )
How satisfied are you with the frequency of your sexual relationship?
1 ( extremely unsatisfied )
2
3
4
5
6
7
8
9
10 ( extremely satisfied )
What is your current level of stress ( overall )
1 ( no stress )
2
3
4
5
6
7
8
9
10 ( extremely satisfied )
What is your current level of stress ( in the relationship )
1 ( no stress )
2
3
4
5
6
7
8
9
10 ( high stress )
Rank order the top three concerns that you have in your relationship with your partner ( 1 being the most problematic )
Do you have feelings of sadness often?
yes
no
Do you worry often?
Do you become angry often?
Check all symptoms you currently are experiencing
Have you every had feelings or thoughts that you didn't want to live?
Yes
No
If yes, please answer the following questions, if no, skip to question asking about children.
How often do you have suicidal thoughts?
Has anything happened recently to make you feel this way?
On a scale of 1 to 1-0 ( ten being strongest) how strong is your desire to kill yourself currently?
Would anything make it better?
Have you ever thought about how you would kill yourself?
Is the method you would use readily available?
Have you planned a time for this?
Is there anything that would stop you from killing yourself?
Do you feel hopeless or worthless?
Have you ever tried to kill or harm yourself before?
Do you have any children? Please list name, age, and biological, step, adopted etc.
Descibe your weekly schedule, do you work? How much time do you spend with partner? children? at work?
Would you like for your time to be spent differenlty, if so how?
Describe how your partner spends time throughout the week, with you, with children, at work, or other.
Do you desire for your partner to spend his/her time differently? If so, please describe.
Do you belong to a particular religion or spiritual group? If so, what is your involvement? How does it affect your life, your relationships?
Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please describe below. If no, state no.
Does your partner have any history of being abused emotionally, sexually, physically or by neglect? If yes, please describe below. If no, state noa
Please tell me anything else you would like for me to know.
