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)
Your answer
What pronouns do you use?
Your answer
Partner's name:
Your answer
How long have you been together?
Your answer
Do you have children? If so, how many? How old?
Your answer
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?
Have you been to couple's counseling before?
Please rate your current satisfaction with your relationship. (1 being completely dissatisfied; 10 being completely satisfied)
Please rate your current DISSATISFACTION with your relationship (10 - completely dissatisfied, 0 not dissatisfied at all)
Please rate your current satisfaction with your sex life.
Please rate your current satisfaction with communication in your relationship.
Do you want to stay in the relationship?
Do you want to leave the relationship?
What keeps you in the relationship?
Your answer
What, if anything, makes you want to leave the relationship?
Your answer
What do you value most about your partner?
Your answer
What do you value most about your relationship?
Your answer
What bugs you most about your relationship? (By "bugs" I mean annoys or frustrates)
Your answer
Is there pain you are carrying in your relationship? Can you name it?
Your answer
Complete the sentence (in as much space as you need): I feel most connected to my partner when...
Your answer
Complete the sentence: I feel most disconnected from my partner when...
Your answer
I feel comfortable talking about our sex life in therapy.
Is there anything about your relationship history (this relationship) that you'd like to share?
Your answer
Is there anything about your own personal relationship history (beyond this relationship) that you'd like to share?
Your answer
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This form was created inside of Katie Hoar.