Couple’s Intake Form Name* First Last Date* MM DD YYYY Phone*May I leave a message?*YesNoEmail* Home address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Employer:*Date of Birth* MM DD YYYY Relationship Status:*(check all that apply) Married Living Together Divorced Separated Living apart Dating Children: Name & ages*What do you hope to accomplish through counseling?*What have you already done to deal with the difficulties?*What are your biggest strengths as a couple?*Please rate your current level of relationship happiness by selecting the number that corresponds with your current feelings about the relationship.*1 being extremely unhappy. 10 being extremely happy.12345678910Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does:*Have you received prior couples counseling related to any of the above problems?*YesNoWhere:*Length of treatment:*Outcome:*Have you been in individual counseling before?*YesNoPlease give a brief summary of concerns you addressed:*Do either you or your partner drink alcohol or take drugs to intoxication?*YesNoWho, how often and what drugs or alcohol?*Do you ever wish your partner would cut back on his/her drinking or drug use?*YesNoN/AHas either of you threatened to separate or divorce (if married) as a result of the current relationship problems?*YesNoWho?*MePartnerBoth of usIf married, have either you or your partner consulted with a mediator and/or lawyer about separation/divorce?*YesNoWho?*MePartnerBoth of usDo you perceive that either you or your partner has withdrawn from the relationship?*YesNoWho?*MePartnerBoth of usHow enjoyable is your sexual relationship?*1 being extremely dissatisfied. 10 being extremely satisfied.12345678910How satisfied are you with the frequency of your sexual relations?*1 being extremely dissatisfied. 10 being extremely satisfied.12345678910What is your current level of stress (overall)?*1 being no stress. 10 being high stress.12345678910What is your current level of stress (in the relationship)?*1 being no stress. 10 being high stress.12345678910Rank the top three concerns you have in your relationship with your partner (1 being the most challenging).