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Marital Counseling Initial Intake Form
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Full Name
*
Date
*
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Spouse Name
*
Address
Street Address
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Relationship Status
*
Married
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Cohabitating
Living in same household
Living apart
Length of time in current relationship?
What are the challenges that you are facing that has led you to decide to seek couples therapy?
Please rate your current level of marital happiness by circling the number which corresponds with your current feelings about the relationship.
*
0 Extemely Unhappy
1 Fairly Unhappy
2 A Little Unhappy
3 Happy
4 Very Happy
5 Extremely Happy
6 Perfect
Have you ever been to counseling as a result of problems with this relationship prior to today?
*
Has either you or your partner been in individual counseling before?
*
If so, give a brief summary
*
If yes for either, who, how often and what drugs or alcohol?
*
Yes
No
If yes for either, who, how often and what drugs or alcohol? Do either you or your partner drink alcohol to intoxication or take drugs to intoxication?
*
Have either you or your partner struck, physically restrained, used violence against or injured the other person within the last three years?
*
Yes
No
If yes for either, who, how often and what happened.
*
Has either of you threatened to separate or divorce as a result of the current marital problems?
*
Has either you or your partner consulted with a lawyer about divorce?
*
Yes
No
If yes, who?
*
Do you perceive that either you or your partner has withdrawn from the marriage?
*
Yes
No
If yes, which of you has withdrawn?
*
How frequently have you had sexual relations during the last month?
*
How enjoyable is your sexual relationship?
*
Terrible
More unpleasant than pleasant
Not pleasant, not unpleasant
More pleasant than unpleasant
Great
How satisfied are you with the frequency of your sexual relations?
*
Way too often to suit me
A bit too often to suit me
About right
A bit too seldom to suit me
Way to seldom to suit me
What is your current level of stress?
*
Extremely high
Very high
High
Moderate
Low
Very low
Extremely low
To what degree do you have family or friends that support you as a couple?
*
Extremely high
Very high
High
Moderate
Low
Very low
Extremely low
To what degree do the two of you share a similar basic worldview?
*
Extremely high
Very high
High
Moderate
Low
Very low
Extremely low
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About
Who we are
Our Practitioners
In The Media
Events
Resources
Careers
Press Release
Testimonials
Shop
Who we are
Our Practitioners
In The Media
Events
Resources
Careers
Press Release
Testimonials
Shop
Concerns
Anxiety
Depression
Grief & Loss
Pain
Anxiety
Depression
Grief & Loss
Pain
Relationships
Sleep Issues
Stress
Trauma
Relationships
Sleep Issues
Stress
Trauma
Our Services
Psychotherapy Services
For Adults
For Children 6-12
For Teens 13-17
For Couples
For Seniors
For Adults
For Children 6-12
For Teens 13-17
For Couples
For Seniors
Other Specialties
BrainTap
Coaching
Grief Guidance
Groups and Workshops
Reiki
BrainTap
Coaching
Grief Guidance
Groups and Workshops
Reiki
Evaluations
CBD Consultation
Brain Tap Assessment
Supplement Assessment
CBD Consultation
Brain Tap Assessment
Supplement Assessment
Forms
Brief Intake
Payment and Insurance
Registration Form
Payment Authorization
Marital Counseling
Initial Intake Form
Marital Counseling
Guidelines and Agreements
Brief Intake
Payment and Insurance
Registration Form
Payment Authorization
Marital Counseling
Initial Intake Form
Marital Counseling
Guidelines and Agreements
Preoperative Psych Evaluation Bariatric Surgery Form
Senior Residential
Referral Intake Form
CBD Waiver
PNP Medication Management
Preoperative Psych Evaluation Bariatric Surgery Form
Senior Residential
Referral Intake Form
CBD Waiver
PNP Medication Management
Insurance
925-216-3510
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