Couples Counseling Initial Intake Form
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4Couples Counseling Initial Intake Form
Name:_________________________________________________
Date: __________________
Name of Partner:________________________________________
Relationship Status:
(check all that apply)
□ Married
□ Cohabitating
□ Separated
□ Living together
□ Divorced
□ Living apart
□ Dating
Length of time in current relationship: _______________
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
Frequency
□ No concern
□ No occurrence
□ Little concern
□ Occurs rarely
□ Moderate concern
□ Occurs sometimes
□ Serious concern
□ Occurs frequently
□ Very serious concern
□ 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?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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