Couples Counseling Initial Intake Form Page 2
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4Please rate your current level of relationship happiness by circling the number that corresponds with
your current feelings about the relationship.
1
2
3
4
5
6
7
8
9
10
(extremely unhappy)
(extremely happy)
Please make at least one suggestion as to something you could personally do to improve the
relationship regardless of what your partner does.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Have you received prior couples counseling related to any of the above problems? □ Yes □ No
If yes, when: _____________________________
Where: _______________________________
By whom: _______________________________
Length of treatment: _____________________
Problems treated: __________________________________________________________________
_________________________________________________________________________________
What was the outcome
?
(check one)
□ Very successful □ Somewhat successful □ Stayed the same □ Somewhat worse □ Much worse
□ Yes □ No
Have either you or your partner been in individual counseling before?
If so, give a brief summary of concerns that you addressed.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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Parent category: Business