Confidential Couples Counseling Intake Form

Each partner in a couple must complete the Confidential Couples Counseling Intake form and initial The Limits of Confidentiality/Therapy Cancellation Policy & Fees form.

Please complete and submit this form prior to your visit.

Client Name*
First Last
Age*
Date of Birth*
MM slash DD slash YYYY
Phone*
Ok to Text Appointment Reminders?*
- Yes
- No
Email*
Email ok for appointment scheduling?*
- Yes
- No
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation
Spouse/Partner Name
CHILDREN
Children Name and Age
Dates of any prior Marriages & Divorces
CURRENT RELATIONSHIP CIRCUMSTANCES
Total years together
Married?
- Yes
- No
Years Married
Marriage date
Pregnancy before Marriage?
- Yes
- No
Why are you seeking therapy at this time?*
CHECK ALL OF THE ITEMS THAT YOU HAVE EXPERIENCED OVER THE PAST MONTH OR ARE EXPERIENCING NOW
- Headaches
- Itching
- Faintness
- Hot flashes
- Dry mouth
- Tightness in jaw
- Muscle spasms
- Overeating
- Cold hands/feet
- Loss of sexual desire
- Twitches, tics, spasm
- Lump in throat
- Stuttering
- Grinding of teeth
- Loneliness
- Suicidal thoughts
- Violent thoughts
- Violent behavior
- Self-Mutilation
- Suicidal attempts
- Sweaty palms
- Weakness in parts of body
- Heavy feeling in arms/legs
- Low motivation
- Tense/nervous
- Waking early
- Breathlessness
- Difficulty w/ decisions
- Feeling inferior to others
- Thoughts of ending your life
- Crying easily
- Lower back pain
- Feeling bored
- Repeated house checking
- Nausea
- Difficulty falling asleep
- Mind going blank
- Feeling fearful
- Ruminating thoughts
- Poor appetite
- Trouble waking up
- Chest pain
- Allergies
- Emotional outbursts
- Fatigue Waking
- Bad dreams
- Fear of places/events
- Trouble remembering
- Difficulty concentrating
- Loss of interest in things
- Sexual functioning issues
Factors contributing to the current marital difficulties.
- Recently had difficulty communicating
- Always had difficulty communicating
- Differences in interests
- Differences in education level
- Differences in ethnic or racial background
- Differences in expectations of marriage
- Differences in expectations about family
- Differences in parenting approach
- Changes in lifestyle, values
- Lack love for one another
- Lack of respect for one another
- Verbal abuse
- Bored
- Sexual difficulties
- In love with another person
- Unfaithful/infidelity
- Abuse or neglect of children
- Job problems
- Suspiciousness, jealousy
- Neglect of home
- Trouble with in-laws
- Drinking
- Excess pornography viewing
- Drug use
- Sexual abuse
- Other
On a scale of 1-10 rate the level of conflict between you and your spouse
1= We get along very well........... 10= We have constant conflict
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
On a scale of 1 to 10 rate how well you and your spouse communicate
1= We communicate very well........... 10= We have great trouble
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Check major life events and/or changes occurring within the last 12 months.
- Started school or training program
- Changed job
- Lost job
- Moved residence
- Financial troubles
- Increase in financial responsibilities
- Legal problems
- Arrested and/or jailed
- Separation or divorce of friend or relative
- Health problems (self, spouse, children)
- Drinking or drug problems
- Began treatment for substance abuse problems
- Began individual therapy
- Began new medications
- Significant weight gain/loss
- Nanny or aging parent joined household
- Nanny or aging parent left household
- Death of pet
- Pregnancy
- Miscarriage
- Abortion
- Fertility problems
- Troubled child
- Onset of menopause
- Mid-life crisis
- Victim of crime
- Auto accident
- Empty nest
What do you hope to accomplish in couples’ therapy? What are your goals?
Current Sources of Emotional Support:
- Friends
- Family
- Neighbors
- Co-workers
- Religion or spiritual practice
- Therapist/counselor
Are you currently employed?
- Yes
- No
How satisfied are you with your current job/work situation?
- Very satisfied
- Moderately satisfied
- Moderately unhappy
- Extremely unhappy
Have you ever had significant health problems or mental illness affecting you for an extended period of time? Please explain.
At present your health is generally:
- Good
- Fair
- Poor
Do you have any history of the following?
- Heart Disease
- Blood Pressure
- Migraines
- Alcoholism
- Irritable bowel syndrome
- Thyroid Problems
- Arteriosclerosis
- Drug Addiction
- Chronic Pain
- Concussion
- Diabetes
- Hepatitis
- Eating Disorder
- Arthritis
- Stroke
- Cancer
What prescription medication do you take currently?
Recreational drug use presently?
- Yes
- No
In the past?
- Yes
- No
If you drink alcohol, how much and how often?
Are you concerned about the drug/alcohol use of your partner? Yes/No If yes, please explain.
Are you currently in couples, family or individual counseling or have you been in the past?
- Yes
- No
Anniversary dates of any significant losses (name and relationship to you)
History or trauma or abuse? Yes/No If yes, please explain.
Have you ever had suicidal thoughts?
- Yes
- No
Have you ever made a suicide attempt?
- Yes
- No
Has anyone in your family committed suicide? Yes/No If yes, what is the relationship to you?
How stressful is your life right now?
- Not
- Mildly
- Moderately
- Extremely
Are you going through menopause?
- Yes
- No
Are you post menopausal?
- Yes
- No
If yes are you taking hormone replacement?
- Yes
- No
How were you referred to me? Google Search/Therapist referral ( If so please provide name)
Beyond the information provided here, what else do you feel is important for me to know about you and your current situation?
Please remember to complete the The Limits of Confidentiality/Therapy Cancellation Policy & Fees form which is found on our Forms Menu.
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Confidential Couples Counseling Intake Form

CHILDREN

CURRENT RELATIONSHIP CIRCUMSTANCES

On a scale of 1-10 rate the level of conflict between you and your spouse

On a scale of 1 to 10 rate how well you and your spouse communicate

Angela Winslow MFT

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