Couples Intake Form

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Couples Counseling Initial Intake

Thank you for completing this form. Be sure to hit 'Submit' when you are finished.
Name*
First Last
Birth Date*
MM slash DD slash YYYY
Age
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
May we leave a message?
- Yes
- No
Cell/Other Phone*
May we leave a message?*
- Yes
- No
Email*
May we email you?*
- Yes
- No
Name of Partner*
First Last
Relationship Status: (check all that apply)*
- Married
- Separated
- Divorced
- Dating
- Cohabiting
- Living Together
- Living Apart
Length of time in current relationship*
Children
Do you have any children?*
- Yes
- No
Please list all children (including those not living at home)
Child's Name Age Date of Birth
General Health and Mental Health Information
Have you previously received any type of mental health services (therapy, psychiatric services, etc.)?*
- No
- Yes
Previous Therapist/Practitioner
Are you currently taking any prescription medication?*
- No
- Yes
Please list
Have you ever been prescribed psychiatric medication?*
- No
- Yes
Please list and provide dates
1. How would you rate your current physical health?*
- Poor
- Unsatisfactory
- Satisfactory
- Good
- Very Good
Please list any specific health problems you are currently experiencing*
2. How would you rate your current sleeping habits?*
- Poor
- Unsatisfactory
- Satisfactory
- Good
- Very Good
Please list any specific sleep problems you are currently experiencing
3. How many times per week do you generally exercise?
Please enter a number from 0 to 50.
What types of exercise to you participate in
4. Please list any difficulties you experience with your appetite or eating patterns
5. Are you currently experiencing overwhelming sadness, grief or depression?*
- No
- Yes
If yes, for approximately how long?
6. Have you had any thoughts of harming yourself or others?*
- No
- Yes
If yes, who have you thought about harming?
How do you plan to harm yourself or others?
Do you have the means to harm yourself or others?
7. Are you currently experiencing anxiety, panic attacks or have any phobias?*
- No
- Yes
If yes, when did you begin experiencing this?
8. Are you currently experiencing any chronic pain?*
- No
- Yes
If yes, please describe
9. Do you drink alcohol more than once a week?*
- No
- Yes
10. How often do you engage in recreational drug use?*
- Daily
- Weekly
- Monthly
- Infrequently
- Never
11. What significant life changes or stressful events have you experienced recently?*
Referred by (if any)
As you think about the primary reason that brings you here, how would you rate its frequency and your overall level of concern at this point in time?
Concern
- No concern
- Little concern
- Moderate concern
- Serious concern
- Very Serious concern
Frequency
- No occurrence
- Occurs rarely
- Occurs sometimes
- Occurs frequently
- Occurs nearly always
What do you hope to accomplish through conseling?*
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 that corresponds with your current feelings about the relationship*
- 1 (extremely unhappy)
- 2 (relatively unhappy)
- 3 (mildly unhappy)
- 4 (a little unhappy)
- 5 (neutral - unhappy)
- 6 (neutral - happy)
- 7 (a little happy)
- 8 (mildly happy)
- 9 (relatively happy)
- 10 (extremely happy)
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?*
- no
- yes
If yes, when
MM slash DD slash YYYY
Where
By whom
Length of treatment
Problems treated
What was the outcome?
- Very successful
- Somewhat successful
- Stayed the same
- Somewhat worse
- Much worse
Have either you or your partner been in individual counseling before?*
- no
- yes
If so, give a brief summary of concerns that you addressed
Do either you or your partner drink alcohol to intoxication or take drugs to intoxication?*
- no
- yes
If yes for either, who, how often and what drugs or alcohol?
Have either you or your partner struck, physically restrained, used violence against or injured the other person?*
- no
- yes
If yes for either, who, how often and what happened
Have either of you threatened to separate or divorce (if married) as a result of the current relationship problems?*
- no
- yes
If yes, who?
- Me
- Partner
- Both of us
If married, have either you or your partner consulted with a lawyer about divorce?*
- no
- yes
If yes, who?
- Me
- Partner
- Both of us
Do you perceive that either you or your partner has withdrawn from the relationship?*
- no
- yes
If yes, which of you has withdrawn?
- Me
- Partner
- Both of us
How frequently have you had sexual relations during the last month? (# times)*
How enjoyable is your sexual relationship?*
- 1 (extremely unpleasant)
- 2 (relatively unpleasant)
- 3 (mildly unpleasant)
- 4 (a little unpleasant)
- 5 (neutral - unpleasant)
- 6 (neutral - pleasant)
- 7 (a little pleasant)
- 8 (mildly pleasant)
- 9 (relatively pleasant)
- 10 (extremely pleasant)
How satisfied are you with the frequency of your sexual relations?*
- 1 (extremely unsatisfied)
- 2 (relatively unsatisfied)
- 3 (mildly unsatisfied)
- 4 (a little unsatisfied)
- 5 (neutral - unsatisfied)
- 6 (neutral - satisfied)
- 7 (a little satisfied)
- 8 (mildly satisfied)
- 9 (relatively satisfied)
- 10 (extremely satisfied)
What is your current level of stress (overall)*
- 1 (no stress)
- 2 (almost no stress)
- 3 (level 3 stressed)
- 4 (level 4 stressed)
- 5 (level 5 stressed)
- 6 (level 6 stressed)
- 7 (level 7 stressed)
- 8 (level 8 stressed)
- 9 (level 9 stressed)
- 10 (highly stressed)
What is your current level of stress (in the relationship)*
- 1 (no stress)
- 2 (almost no stress)
- 3 (level 3 stressed)
- 4 (level 4 stressed)
- 5 (level 5 stressed)
- 6 (level 6 stressed)
- 7 (level 7 stressed)
- 8 (level 8 stressed)
- 9 (level 9 stressed)
- 10 (highly stressed)
Rank in order the top three concerns that you have in your relationship with your partner (1 being the most problematic)
Rank #1
Rank #2
Rank #3
Please note that you will be asked to talk about your answers in sessions but your partner will not be shown this form.

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Contact

Justin, TX 76247-1966
(310) 870-1275

Addressing issues that require a unique treatment approach

Dr. Chris Regan, Psy.D. serves Manhattan Beach, Hermosa Beach, Redondo Beach, Torrance, Rancho Palos Verdes, Palos Verdes Estates, Rolling Hills, Rolling Hills Estates, El Segundo, San Pedro, Carson, Harbor City, Hawthorne, Inglewood, Long Beach, and the Los Angeles South Bay Area.

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Couples Intake Form

Couples Counseling Initial Intake

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