Couples Therapy Intake Questionnaire

* - Required fields
*Your name

*Your email

Please check any of the following that you have experienced in the past 6 months:
HeadacheHigh Blood PressureIrritable BowelChronic PainLoss of ConsciousnessChronic FatigueDizzinessFaintnessShortness of BreathIncreased AppetiteDecreased AppetiteEating ProblemsExcessive EatingTrouble ConcentratingSleeping DifficultiesExcessive SleepLack of Need for SleepLow MotivationLow Self-EsteemDepressed MoodLoss of Interest or PleasureTearing or Crying SpellsHopelessnessAnxietyFearPanicDelusionsHallucinationsMood SwingsExcessive EnergyImpulsivitySensation Seeking BehaviorIrritability and/or AngerParanoiaFlashbacksNightmaresIsolation from OthersWithdrawal from OthersThoughts of DeathEngaging in Self-Harming Behavior(s)Other










*
*

What coping strategies do you use during a stressful time? Please select all that apply:
Relaxation TechniquesExercise/Recreational ActivitiesEngage in Personal HobbiesTurn to SpiritualityEmotionally EatVent to friends and/or family membersWithdraw from othersAvoidanceUse HumorOther
*
*




How would you rate your happiness level in your current romantic relationship from 1-10?—Please choose an option—12345678910
*




What issues are currently affecting your relationship with your partner? Please select all that apply: CommunicationTrust IssuesAffectionSexual IntimacyLack of Emotional SupportSpending Quality Time TogetherExtra-Relationship AffairSelf-Esteem IssuesTemper OutburstsLoss of IndependenceJob IssuesDivision of Household WorkBlended Family IssuesDealing with Extended FamilyFinancesLegal IssuesChronic IllnessDeath
*

Is sexual intimacy an issue in your relationship? Please select all issues that apply:Frequency of SexBeing able to candidly talk about sexual problemsLack of RomanceSexual Dysfunction(s)Other




When disagreements arise between you and your partner, which of these reactions do YOU typically display? Select all that apply: Physical AggressivenessVerbal AggressivenessTemper OutburstsAngerWithdrawnDefensiveCriticize PartnerAvoidanceShutting DownPressure to Communicate ImmediatelyDenialMake Excuses/Justifications for Actions
When disagreements arise between you and your partner, which of these reactions does HE or SHE typically display? Select all that apply:Physical AggressivenessVerbal AggressivenessTemper OutburstsAngerWithdrawnDefensiveCriticize PartnerAvoidanceShutting DownPressure to Communicate ImmediatelyDenialMake Excuses/Justifications for Actions




|
Which of the following did you experience as a child? Please select and answer to all that apply:
I and/or a family member was physically, emotionally, or sexually abused as a child.
My family members(s) suffered from a mental illness.
One or both of my parents/caregivers struggled with substance use.
I lived in a single-parent home.
One or both of my parents were emotionally unavailable or absent.
My parents did not make me feel good about myself.Affection was not expressed in my family.My parents were not emotionally expressive.I did not spend quality time with my family as a child.I was not able to depend on my parents for help.My family struggled financially.I did not have a supportive relationship with my siblings.My home was not open socially to guests or visitors.I felt criticized by my parents.My parents used inconsistent and punitive punishment towards me and/or my siblings.I was abused and/or bullied by my peers.I lived in a blended family.I did not have a good relationship with my step-family member(s).I generally feel like I had a good childhood.

*I consent to having this website store my submitted information so they can respond to my inquiry.GDPR Agreement

Δ