Couples Counseling Intake Form

Please answer all the questions below, using a separate form for each partner.

The information you provide here is protected as confidential information. Please note that you may be asked in sessions to talk about the information you provide, but your partner will not be shown this form.

Please fill out and submit this form prior to your first session.
Date form completed:
Month
Day
Year
Name:
First Last
Name of Partner:
First Last
- Phone
- May we leave a message?
  - Yes
  - No
- Email
- May we Email you?
  - Yes
  - No
- In case of emergency, contact:
  First Last
- Phone
- Relationship status (Please describe; married, separated, dating, cohabiting, etc. )
- Please list any children, including name and age:
- Length of time in current relationship:
1. What is the primary issue that brings you here?
2. AS YOU THINK ABOUT THE PRIMARY REASON THAT BRINGS YOU HERE, PLEASE RATE THE OVERALL LEVEL OF CONCERN AND FREQUENCY AT THIS POINT.
- Concern:
  - No concern
  - Little concern
  - Moderate concern
  - Serious concern
  - Very serious concern
- Frequency
  - No occurrence
  - Occurs rarely
  - Occurs sometimes
  - Occurs frequently
  - Occurs nearly always