Date
MM
DD
YYYY
Your Name
*
First Name
Last Name
Partners Name
*
First Name
Last Name
Email
*
Address
*
Contact Number
*
Gender Identity
*
Date Of Birth
*
MM
DD
YYYY
Age
*
Occupation (Paid or Unpaid)
*
Name and Address of GP Surgery:
*
Are you taking any medication to help with for mood and/or behaviour?
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Are you taking any medication or substance that adversely affects your mood or behaviour?
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Name and number of someone we can call in emergency:
*
Relationship Status:
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Check all boxes that apply to you
How long have you been together?
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Do you have children or step children? If so what are their ages?
*
What brought you together? What was your initial attraction?
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What is the primary reason you are seeking couple counselling?
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Are there any major stressors/sources of stress in your life right now, such as loss, sickness, work, money obligations, past trauma, etc?
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Do you ever feel suicidal or feel you don't want to live anymore?
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If so, do you ever feel close to acting it out?
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Our sexual relationship is enjoyable:
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I am satisfied with the frequency of our sexual relationship.:
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Any further comments about your sexual relationship. (optional) Such as Erectile Disfunction, Low Libido, Inability to Orgasm, Issues with Who Initiates, Wandering Mind, Baby Pressure, Premature Ejaculation, Feeling Pressured to Engage in Certain Sexual Activities, Difficulty Discussing the Subject and anything else:
What do you hope to accomplish through counselling?
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What have you already done to deal with the difficulties?
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What are your biggest strengths as a couple?
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Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does:
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Have you received prior couples counselling related to any of the above problems? If Yes, please give details of when and duration of treatment:
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Have you been in individual counselling before? If so, give a brief summary of concerns that you addressed:
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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?
*
Have either you or your partner struck, physically restrained, used violence against or injured the other person? If yes for either, who, how often and what happened:
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What are the top three concerns that you have in your relationship with your partner?
*
What do you appreciate about the relationship?
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Is there anything else you want to say?
