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Couple Therapy Intake Form
Personal Information
First Name
Last Name
Email
Phone
Birthday
First Name
Last Name
Email
Phone
Birthday
Relationship Status
We are:
Married
Separated
Divorced
Dating
We live:
Together
Apart
We’ve been together for:
We belong to this religious/spiritual group:
We've had history of: (Check all that apply)
Drug/Alcohol Problems
Physical Abuse
Legal Trouble
Sexual Abuse
Divorce
Separation
Presenting Problem
What Is Going On?
Duration
How Long Has This Been Going?
Frequency
Has This Occurred Before?
Prior Interventions
If yes, list previous professional(s) seen, describe treatment
Aggravating Factors
What makes things worse?
Relieving Factors
What makes things better?
Additional Information
What else would you like to share?
Goals
What are you hoping to achieve?
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