Couples Intake Questionnaire

Thank you for taking the time to complete this questionnaire. These questions are only used to help understand if we are the right facilitators to hold space, and to curate a program tailored to your situation. Whilst the form does not require personal identification details to maintain confidentiality, we do need to know who has submitted the questionnaire - so please only enter your code reference and not your name. There is no need to share personal situation information unless you feel you would like to. Prior to the session there will be a preparation conversation where situational items can be discussed.

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* 1. Reference

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* 2. Length of relationship in years:

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* 3. If you have children, the age of youngest child:

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* 4. We have engaged in couples therapy of some form in the past:

No.

Yes- and it was helpful.

Yes- and it wasn't very helpful.

Other (please specify)

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* 5. The desire to do the couples session:

Each are similarly enthusiastic to do a couples session.

One is more enthusiastic than the other, but the other is willing.

One is more enthusiastic than the other, and the other is only doing it because the other wants them to.

Other (please specify)

We find relationships can be an ever moving continuum between various different conditions. Please slide the scale to where you feel you are at this moment between these two conditions. Try to be approximately right based on your own feelings, not what you think your partner may believe.

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* 6. Our current relationship continuum is

Mostly destructive conflict with challenges in respect and communication.

We move between conflict and connection.

Any conflict is constructive; we have strong respect, communication, and deep love.

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 7. Our core goals for this session:

Have a beautiful experience together to just simply connect and grow as a couple.

Resolve some areas of challenge/conflict.

Assist one or both participants to unpack and resolve personal behaviours, feelings and/or thoughts.

A bit of all of the above.

Other (please specify)

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* 8. Coming into the session:

Happy to go with the facilitator flow.

I know where I would like to start.

Other (please specify)

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* 9. Our individual relationship needs are:

Understood and provided in the relationship by each partner.

Understood however one or both partners may have difficult meeting the other partner's needs.

Not understood by one or both partners.

Other (please specify)

Couples Intake Questionnaire

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* 1. Reference

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* 2. Length of relationship in years:

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* 3. If you have children, the age of youngest child:

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* 4. We have engaged in couples therapy of some form in the past:

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* 5. The desire to do the couples session:

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* 6. Our current relationship continuum is

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* 7. Our core goals for this session:

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* 8. Coming into the session:

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* 9. Our individual relationship needs are:

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* 10. I would like to share the following at this point (optional):