Welcome to couple's counseling!
Instructions:
Please complete this initial form AHEAD of your first session. This is DIFFERENT than the "New Client Form" - it will serve as a starting point for our work together. This is to be completed INDIVIDUALLY. Please do not complete with your partner. Please do try to refrain from sharing responses with your partner ahead of time. If you have questions, feel free to reach out to me at katie@fireflycounselingvt.com.
Name: (full and preferred, please)
What pronouns do you use?
Partner's name:
How long have you been together?
Do you have children? If so, how many? How old?
Select all that apply about your relationship (use the "other" if I am missing something you'd like to add):
Have you been to therapy before?
Clear selection
Have you been to couple's counseling before?
Please rate your current satisfaction with your relationship. (1 being completely dissatisfied; 10 being completely satisfied)
Clear selection
Please rate your current DISSATISFACTION with your relationship (10 - completely dissatisfied, 0 not dissatisfied at all)
Clear selection
Please rate your current satisfaction with your sex life.
Clear selection
Please rate your current DISSATISFACTION with your sex life.
Clear selection
Please rate your current satisfaction with communication in your relationship.
Clear selection
What do you communicate well about? What is harder to communicate about? Are there any topics that seem to be "taboo" or off-limits in your relationship?
Do you want to stay in the relationship?
Do you want to leave the relationship?
Clear selection
What keeps you in the relationship?
What, if anything, makes you want to leave the relationship?
What do you value most about your partner?
What do you value most about your relationship?
What bugs you most about your relationship? (By "bugs" I mean annoys or frustrates)
Is there pain you are carrying in your relationship? Can you name it?
Complete the sentence (in as much space as you need): I feel most connected to my partner when...
Complete the sentence: I feel most disconnected from my partner when...
I feel comfortable talking about our sex life in therapy.
Clear selection
Is there anything about your relationship history (this relationship) that you'd like to share?
Is there anything about your own personal relationship history (beyond this relationship) that you'd like to share?
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This form was created inside of Katie Hoar.