Couples Counseling Initial Intake Form Page 2
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3 Yes No
Have either you been in individual counseling before?
If so, give a brief summary of concerns you addressed.
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Yes No
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?
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Do you ever wish your partner would cut back on his/her drinking or drug use? Yes No
N/A
Have either you or your partner struck, physically restrained, used violence against or injured the other person?
Yes No
If yes, who, how often and what happened?
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Has either of you threatened to separate or divorce (if married) as a result of the current relationship problems?
Yes No
Me Partner
Both of us
If yes, who?
If married, have either you or your partner consulted with a lawyer about divorce?
Yes No
Me Partner
Both of us
If yes, who?
Do you perceive that either you or your partner has withdrawn from the relationship?
Yes No
Me Partner
Both of us
If yes, who?
How enjoyable is your sexual relationship? (Circle one)
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(
extremely unpleasant)
(extremely pleasant)
How satisfied are you with the frequency of your sexual relations? (Circle one)
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(
extremely unsatisfied)
(extremely satisfied)
What is your current level of stress (overall)? (Circle one)
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no stress)
(high stress)
What is your current level of stress (in the relationship)
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no stress)
(high stress)
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