Genine Leighton, MS, MFT

Licensed Marriage and Family Therapist

Please contact me to set up an appointment!

Genine Leighton, MFT
831-566-6830
genine@genineleighton.com

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Couple’s Intake Form

Name*
First Last
Date*
MM
DD
YYYY
Phone*
May I leave a message?*
- Yes
- No
Email*
Home address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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.
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Please 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?*
- Yes
- No
Where:*
Length of treatment:*
Outcome:*
Have you been in individual counseling before?*
- Yes
- No
Please give a brief summary of concerns you addressed:*
Do either you or your partner drink alcohol or take drugs to intoxication?*
- Yes
- No
Who, how often and what drugs or alcohol?*
Do you ever wish your partner would cut back on his/her drinking or drug use?*
- Yes
- No
- N/A
Has either of you threatened to separate or divorce (if married) as a result of the current relationship problems?*
- Yes
- No
Who?*
- Me
- Partner
- Both of us
If married, have either you or your partner consulted with a mediator and/or lawyer about separation/divorce?*
- Yes
- No
Who?*
- Me
- Partner
- Both of us
Do you perceive that either you or your partner has withdrawn from the relationship?*
- Yes
- No
Who?*
- Me
- Partner
- Both of us
How enjoyable is your sexual relationship?*
1 being extremely dissatisfied. 10 being extremely satisfied.
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
How satisfied are you with the frequency of your sexual relations?*
1 being extremely dissatisfied. 10 being extremely satisfied.
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
What is your current level of stress (overall)?*
1 being no stress. 10 being high stress.
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
What is your current level of stress (in the relationship)?*
1 being no stress. 10 being high stress.
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Rank the top three concerns you have in your relationship with your partner (1 being the most challenging).