Couples Therapy Intake | Beverly Hills Psychologist

Couples Intake Questionnaire

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Welcome. I’m pleased that you have chosen to take this step. I look forward to working with you.

This questionnaire is for the purpose of getting to know you better in order to provide the best possible mental health services. Please complete this form as honestly and completely as possible. All information that you provide us will be confidential as required by state and federal law.
Name*
First Last
Age*
Email*
Relationship status*
Years together*
Please be sure to first complete the individual adult intake prior to this one. Check each of the following symptoms you are currently or have experienced within the past 6 months.
Relationship Issues*
- Affection
- Holding other back
- Sexual Issues
- Agreeing on chores
- Housing
- Showing appreciation
- Closeness
- Infidelity
- Solving problems together
- Common Goals
- In-laws
- Spouses/partner’s cleanliness
- Common interests
- Jealousy
- Trusting each other
- Communication
- Parenting
- Use of time
- Finances
- Physical fighting
- Verbal fighting
- Friendships
- Recreation
- Guilt / Shame
- Relatives
- Having fun together
What is the problem that led you to decide to come to couples therapy?*
What are the things you like most about your relationship?*
What are the things you most want to change?*
How often do you argue?*
What do you most often argue about?*
Do you or your partner tend to attack the other personally and/or resort to ugly name calling? Why? Please elaborate:*
Describe your most recent argument. How did it start? How did it end?*
When you do argue, does someone end up leaving? Who? How long before they come back?*
How long do you tend to stay mad at each other?*
Who is usually the first to attempt to make things better?*
Do your arguments ever get physical? Because of you or your partner?*

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Who initiates sex most often? Do you feel comfortable with that arrangement?*
Do you ever feel forced to have sex with them? Do you ever force them to have sex with you?*
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? How did you meet?*
What was the beginning of your relationship like and how long did this phase last?*
How did you make the decision to live together or not, or to marry?*
What red flags did you choose to ignore at the beginning? How did that affect your relationship and why?*
Do you feel that you or your partner are emotionally unavailable? How does that affect your relationship?*
Do you trust your partner? Does your partner trust you? Why not?*
Do you ever feel like you have to play detective? Why? How did this start?*
What happened that first caused you to feel disillusioned with your partner? Did this lead to any changes in your relationship?*
Do you have children? If so, please name them with their current ages, and any special issues your children might have that impact your relationship with your partner.*
Do you have any pets? Please be specific, i.e. types, names, ages, and any issues your pets may have that impact in your relationship.*
How are the two or you similar and how are you different?*
What do you do when there is conflict between the two of you? What does your partner do?*
What do you do when you are angry with him? What does your partner do when angry with you?*
What strengths and weaknesses do you have in resolving conflict? What would you say are your partner’s strengths and weaknesses in resolving conflict?*
Do you enjoy being involved in activities separate from you partner? What do you like to do in those situations?*
Does your partner make time for you? How? Are you satisfied with it?*
How comfortable are you if your partner spends free time away from you?*
Does your use of your free time or your partner’s create conflict in your relationship?*
Do you have separate friendships with people who are not mutual friends?*
Does this create jealousy and/or conflict in your relationship?*
Do you keep important secrets from your relationship?*
Are there things about you or your past that you would never share with your partner and why?*
Do you have relationships with other people that create conflict with your partner, and if so, why?*

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How do your friendships outside your partnership support your partnership? Do you have friends who want to see the relationship thrive? Do you have friends who want to see the relationship fail? Describe:*
On a scale of 1 to 10, how aware or in touch with your emotions are you (1=not at all and 10=extremely)? Explain the rating you give yourself.*
On a scale of 1 to 10, how open are you in expressing your innermost feelings, desires and thoughts to your partner (1=totally closed and 10=totally open)? Explain the rating you give yourself.*
On a scale of 1 to 10, how aware or in touch is your partner with their emotions (1=not at all and 10=extremely)? Explain the rating you give them.*
On a scale of 1 to 10, how open is your partner in expressing their innermost feelings, desires and thoughts to you? (1=totally closed and 10=totally open)? Explain the rating you give them*
What is the area or topic that it is most difficult for you to open with your partner about? Why?*
When your partner wants support or encouragement from you do you feel that you give it? How?*
Are you happy/proud with your own education/career/income? Please elaborate:*
Are you happy/proud of your partner's education/career/income? Please elaborate:*
To what degree do the two of you share a similar basic worldview? (Circle one) Extremely high Very high High Moderate Low Very low Extremely low*
Describe your sexual relationship. What do you find most satisfying about it? What don’t you like about it? How has your sexual relationship changed since you were first together?*
What is one thing that you wish were different about your sexual relationship?*
Are you still sexually attracted to your partner? What about them do you find attractive or not?*
Are you happy with your partner’s grooming habits? If not, what would need to change?*
Who does the majority of the household chores, grocery shopping, cooking? Are you happy with this present arrangement? How was it decided? How would you like it to change?*
Do you feel your partner is supportive and understanding as well as willing to share in the burdens of the household?*
How do you handle finances? Who is in charge? Do you keep finances separate or combined?*
How are you similar or different about how you handle money, spending and saving?*

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Are you and your partner financially responsible?*
Who is the bigger income earner? Do they bring that up frequently, why?*
Do you contribute to household expenses equally or proportionately to your income?*
Did either one of you come into the relationship with significant debt? Why? How was it negotiated?*
Do you carry a lot of debt currently? Why?*
Is one of you is more impulsive/careless with spending? Why?*
When do you feel most content in your relationship? When do you feel most unhappy or frustrated?*
On a scale of 1 to 10, describe your level of commitment to your relationship (1=not at all, 10= extremely). Explain the rating you give yourself.*
On a scale of 1 to 10, how much do you still love your partner (1=not at all, 10=very deeply)? Explain the rating you give yourself.*
On a scale of 1 to 10, how much do you respect your partner (1=not at all, 10=very highly)? What is it about him that creates that level of respect in you?*
What role have you played in contributing to the problems in your relationship; what tendencies do you have and what actions have you taken that have helped create or have added to the difficulties between you two?*
If your relationship was a book or a movie, what would it be titled? And how would it end?*
Have you received prior couples counseling related to any of the above problems?*
- Yes
- No
Treatment*
When Where By whom Length of treatment Problems treated
What was the outcome (check one)?*
- Very successful
- Somewhat successful
- Stayed the same
- Somewhat worse
- Much worse
Why?*
Have either you or your partner struck, physically restrained, used violence against or injured the other person?*
- Yes
- No
who, how often and what happened?*
Has either of you threatened to separate or divorce (if married) as a result of the current relationship problems?*
- Yes
- No
*
Who? Why?
If married, have either you or your partner consulted with a lawyer about divorce?
- Yes
- No
Who? Why?
Do you perceive that either you or your partner has withdrawn from the relationship?*
- Yes
- No
*
which of you has withdrawn? Why? How long?
How frequently have you had sexual relations during the last month?*

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How enjoyable is your sexual relationship? (select one) 1 2 3 4 5 6 7 8 9 10 (extremely unpleasant) (extremely pleasant) Please explain:*
How satisfied are you with the frequency of your sexual relations? (select one) 1 2 3 4 5 6 7 8 9 10 (extremely unsatisfied) (extremely satisfied) Please explain:*
What is your current level of stress (in the relationship)? (select one) 1 2 3 4 5 6 7 8 9 10 (no stress) (high stress) Please explain:*

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

Which of these problems, issues or questions do you wish to address in counseling at this time? Why now?*
Which of these problems are you primarily responsible for and which are the responsibility of others? Who are these other persons?*
What have you already done to deal with the difficulties?*
On a scale of 1 to 10, how open are you in expressing your innermost wants, thoughts, desires, and feelings to your partner? (1 is totally closed and 10 is totally open.) Describe:*
From whom do you receive support and encouragement?*
When you feel like you want support or encouragement from your partner, do you get it? How?*
Do you support your partner's development as an individual? How? (Please give an example)*
Do you support their growth as an individual even when you don't agree? How? (Please give an example)*
Do the two of you have joint commitments to goals, projects, work, spirituality, religion or social causes? Does this add or detract from the bond between you?*
What do you admire most about your partner?*
What are some of the things you appreciate about your relationship?*
What makes you feel safe in your relationship?*
Have you had previous relationships? Have you noticed any patterns that you have repeated throughout your history of relationships? Please elaborate:*
What are your biggest strengths as a couple?*
What changes do you believe you need to make in yourself to have a successful romantic relationship?*
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Your Name* *

Your Email *

Your Personal Mobile Phone Number* *

Location of Sessions *

Session Type Needed: *

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What Is Your Current Top Concern? *

What Is The Current Trend Of Your Top Concern? *

How Long Have You Been Dealing With Your Top Concern? *

Are You Currently Experiencing Any Suicidal/Self-Harm Thoughts? *

How Would You Describe Your Usual Conversational Style? *

Who Referred You To Us? *

Comment or Message *

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Phone: +1 (310) 500 8442
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