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DOB
Address
Mailing Address (if different)
Marital Status
Home Phone
Work Phone
Cell Phone
Email *
Place of Employment
Address
Position
Not Working Because
If yes, for what problems?
When (Couples counseling)
Where (Couples counseling)
Therapist (Couples counseling)
Length of treatment (Couples counseling)
Was the outcome successful? (Couples counseling) Very Very Somewhat No Change Got Worse
If yes, give a summary of concerns you addressed
When (Individual Counseling)
Where (Individual Counseling)
Therapist (Individual Counseling)
Length of treatment (Individual Counseling)
Was the outcome successful? (Individual Counseling) Very Very Somewhat No Change Got Worse
Please list any psychiatric problems you have been diagnosed with
Please list any medical or “physical” problems that you have been diagnosed with
Please list any medications you currently take, and what you take them for
Name of Psychiatrist
Phone
Practice Name
Address
Date of last appointment
Please describe in detail those you have selected
How long have you been married, cohabiting, separated, or divorced
What do you do when there is conflict between the two of you? What does your partner do?
What do you do when you are angry? What does your partner do when angry?
What strengths do you have that support resolving differences? What strengths does your partner have?
Do you spend time alone? Do you enjoy your free time? Does planning how to spend it create anxiety for you?
Do you have separate friendships with people who are not mutual friends? Does this create conflict in your relationship?
When you feel like you want support or encouragement from your partner, do you get it? How? When your partner wants support or encouragement from you, do you feel that you give it? How?
Do you support your partner’s development as an individual? How (give an example)?
Please rate your current level of relationship satisfaction by circling the number that corresponds with your current feelings about the relationship 1 Extremely Unsatisfied 1 Extremely Unsatisfied 2 Unsatisfied 3 Nuetral 4 Satisfied 5 Extremely Satisfied
How satisfied are you in expressing your innermost wants, thoughts, desires, and feelings to your partner? (copy) 1 Extremely Unsatisfied 1 Extremely Unsatisfied 2 Unsatisfied 3 Nuetral 4 Satisfied 5 Extremely Satisfied
How satisfied are you with the frequency of your sexual activities? 1 Extremely Unsatisfied 1 Extremely Unsatisfied 2 Unsatisfied 3 Nuetral 4 Satisfied 5 Extremely Satisfied
How satisfied are you with the quality of your sexual activities? 1 Extremely Unsatisfied 1 Extremely Unsatisfied 2 Unsatisfied 3 Nuetral 4 Satisfied 5 Extremely Satisfied
What is your current level of stress in the relationship? 1 Extremely Unsatisfied 1 Extremely Unsatisfied 2 Unsatisfied 3 Nuetral 4 Satisfied 5 Extremely Satisfied
hospitalized do your
If yes for either, who, how often and what drug/alcohol?
What have you already tried to address these difficulties?
Was there a prompting event that led someone to make this call? (Why seek help now?)
What are your biggest strengths as a couple?
Please make at least three suggestions as to something you could personally do to improve the relationship regardless of what your partner does
How important is it to you to improve the quality of your relationship? 1 Extremely Not Important 1 Extremely Not Important 2 Not Important 3 Nuetral 4 Important 5 Extremely Important
How willing are you to make “working on this relationship” a priority in your life? 1 Extremely Not Willing 1 Extremely Not Willing 2 Not Willing 3 Nuetral 4 Willing 5 Extremely Willing
If your relationship were a movie, drama, or book, what would it be titled? How would it end?
Is there anything else that you would like to mention?