Relationship Questionnarie Intake Form

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Your name & Your partners name

Select from dropdown

How long have you been in this relationship?

If married, how long have you been married? If you lived together before marriage, how long?

Do you have children? If yes please list the names and ages, and who currently lives at home?

What issues are bringing you to counseling/coaching?

What goals do you have for your relationship?

Have you had therapy or couples counseling in the past? Is so, what and when?

What was helpful?

What was not helpful?

What are your biggest strengths as a couple?

Please rate your current level of happiness from 1-10 that correspond with your current feelings about the relationship?

What traits do you appreciate in your partner?

What traits do you think your partner appreciates in you?

Describe 2 behaviors which you personally could change to make your relationship better:

Describe 2 of your partner’s behaviors which are challenging to you:

Has either of you threatened to separate or divorce (if married) as a result of the current relationship problems?

How enjoyable is your sexual relationship from 1 -10?

What is your current level of stress (overall)?

What is your current level of stress (in the relationship)?

Please rate your communication skills from 1-10?

What are the main stresses in your relationship?

Rank the order of the top three concerns you have in your relationship with your partner (1 being the most problematic)

If you had a magic wand what would be the ideal solution for your problems?

On a scale of 1-10 how much do you want to change the current state of your relationship/marriage?

What are you willing to do to create the changes you desire?

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