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 SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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).