Intake Questionnaire Couple/Marriage

Kindly complete the online form as thoroughly as possible. If you prefer to download and fill out the form offline, please download and email it to info@pranamind.com it at your convenience.

Please enable JavaScript in your browser to complete this form.
Name
Multiple Choice
(Please Provide Name, Relation, Sex & Age)
Multiple Choice
Have you received prior couples counseling?
Have you previously or are you currently in individual counseling before?
Have you been hospitalized for a psychiatric illness?
Check all that apply, recent or current stressful life events you or your family have been experiencing
Do either you or your partner drink alcohol or take drugs to intoxicate?
Has either of you threatened to separate/divorce because of the current relationship problems?
If yes, who?
Do you perceive that either you or your partner has withdrawn from the relationship?
If yes, who?
Have you or your partner ever emotionally or physically cheated on each other?
If yes, who?
What are your treatment goals (check all that apply):
Whose idea was it to come to therapy?