Name
*
First Name
Last Name
Email Address
*
What lead you to seek couples counseling/ coaching? Why now?
What about your relationship is positive? What would you like to be different?
What would you like to accomplish in coaching as an individual? For your relationship?
What individual strengths do you bring the relationship?
What strengths does your partner bring?
How long have you and your partner been together? In what form (e.g., dating, living together, married)?
What initially attracted you to your partner?
What was the beginning of your relationship like and how long did this phase last? What is different now? What was the cause of that change?
Have either of you been married before?
No
I was married
My partner was married
We were both married
Do you or your partner have children from a previous relationship?
No
My partner has children
I have children
We both have children
Have you participated in individual or couples coaching/therapy with this partner before?
No
Individual
Couples coaching/therapy
Both individual and couples coaching/ therapy
Please rate your current level of relationship satisfaction from 1-10 (1 being lowest, 10 being highest)
1
2
3
4
5
6
7
8
9
10
Has either of you suggested to separate or divorce (if married) as a result of the current relationship problems?
Yes
No
Please rate your current level of commitment to your relationship (1 being lowest, 10 being highest)
1
2
3
4
5
6
7
8
9
10
What stresses have you and your partner experienced in the last 2 years (check all that apply)
Describe your parents’ relationship to one another (check all that apply)
Were there experiences you had that felt overwhelming during childhood? If so, what?
Who did you go to for comfort as a child? Did they generally understand and meet your needs?
Do either you or your partner drink alcohol or take drugs to intoxication? Please briefly describe.
My use of alcohol or other substances causes problems in the relationship
Yes
No
My partner’s use of alcohol or other substances causes problems in the relationship.
Yes
No
I experience significant mood-related challenges (depression, anxiety, fear, self-harm, suicidal thoughts, thoughts of hurting others) that contribute to problems in the relationship.
Yes
No
...If yes, please briefly describe:
My partner experiences significant mood-related challenges (depression, anxiety, fear, self-harm, suicidal thoughts, thoughts of hurting others) that contribute to problems in the relationship.
Yes
No
...If yes, please briefly describe:
Have either you or your partner struck, physically restrained, used violence against or injured the other?
Yes
No
Have either you or your partner been emotionally or verbally abusive toward the other?
Yes
No
Have either you or your partner pressured or forced the other to engage in sex even when they express they do not want to?
Yes
No
Do you trust your partner?
Yes
No
If no, why not?
On a scale of 1 to 10, how open are you in expressing your innermost feelings, desires and thoughts to your partner? (1 being lowest, 10 being highest)
1
2
3
4
5
6
7
8
9
10
What is the area or topic that it is most difficult for you to open with your partner about? Why?
Have either of you had an affair during your relationship (or an inappropriate outside relationship)?
Yes
No
...If yes, briefly describe:
Are there are specific events in your relationship which you are having trouble getting over?
Yes
No
...If yes, what?
Do you enjoy being involved in activities separate from your partner? What do you like to do in those situations?
Do you have separate friendships with people who are not mutual friends?
Yes
No
...If yes, does this create conflict in your relationship?
Yes
No
How satisfied are you with your social life? (1 being not, 10 being very)
1
2
3
4
5
6
7
8
9
10
How satisfied are you in pursuing interests and hobbies? (1 being not, 10 being very)
1
2
3
4
5
6
7
8
9
10
How comfortable are you with your partner spending time away from you? (1 being not, 10 being very)
1
2
3
4
5
6
7
8
9
10
How do you encourage your partner’s development as an individual?
How do you advocate for your own continued personal development?
In one sentence, describe your sexual relationship.
How enjoyable is your sexual relationship? (1 being not, 10 being very)
1
2
3
4
5
6
7
8
9
10
What do you find most satisfying about it?
What don’t you like about it?
How satisfied are you with the frequency of your sexual relations? (1 being not, 10 being very)
1
2
3
4
5
6
7
8
9
10
Who initiates sex most often?
Me
My partner
We both initiate equally
Neither initiates
How has your sexual relationship changed since you were first together?
Do you have concerns about any of the following? (check all that apply)
Feeling used sexually
Do you think you or your partner have trouble communicating?
Yes
No
If yes, check which of the following apply:
How often do you argue?
When you do argue, does someone end up leaving? Who?
Who is usually the first to attempt to make up?
Me
My partner
We both make the effort equally
Neither makes an effort for some time
Do you feel misunderstood by your partner?
No, not generally
Yes, often
Only during certain conflicts
What is your current level of stress in your life? (1 being none, 10 being high)
1
2
3
4
5
6
7
8
9
10
What is your current level of stress in your relationship? (1 being none, 10 being high)
1
2
3
4
5
6
7
8
9
10
Are you clear about your responsibilities in the relationship?
Yes
No
How do you feel about those responsibilities?
Can you rely on your partner to uphold their responsibilities to you and the relationship?
Yes
No
Do you experience stress related to any of the following? (select all that apply)
What else would you like us to know before meeting you and your partner?
How did you hear about us?