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Marriage Medicines (Let's Meet You)
* Indicates required question
Email
*
Record my email address with my response
NAME (First)
*
Your answer
NAME (Last)
*
Your answer
DATE OF BIRTH
*
MM
/
DD
/
YYYY
INTAKE DATE
*
MM
/
DD
/
YYYY
PARTNER'S NAME (OPTIONAL)
Your answer
CELL PHONE
*
Your answer
EMAIL
*
Your answer
RELATIONSHIP STATUS
*
MARRIED
SEPERATED
DIVORCED
DATING
COHABITATING
ENGAGED
LIVING APART
SINGLE
REMARRIAGE
Other:
Required
REASON FOR COUNSELING
*
COUPLES COUNSELING
INDIVIDUAL FEMALE
INDIVIDUAL MALE
REMARRIAGE
DATING
COURTSHIP
PREMARTIAL
Other:
Required
LENGTH OF TIME IN CURRENT RELATIONSHIP
*
Your answer
AS YOU THINK OF THE PRIMARY REASON THAT BRINGS YOU HERE, HOW WOULD YOU RATE YOUR OVERALL
LEVEL OF CONCERN
NOW?
*
NO CONCERN
LITTLE CONCERN
MODERATE CONCERN
SERIOUS CONCERN
PROFOUNDLY SERIOUS CONCERN
Other:
AS YOU THINK OF THE PRIMARY REASON THAT BRINGS YOU HERE, HOW WOULD YOU RATE ITS
FREQUENCY
?
*
NO OCCURRENCE
OCCURS RARELY
OCCURS SOMETIMES
OCCURS FREQUENTLY
OCCURS NEARLY ALWAYS
Other:
WHAT DO YOU HOPE TO ACCOMPLISH THROUGH COUNSELING?
*
Your answer
WHAT HAVE YOU ALREADY DONE TO DEAL WITH THE CHALLENGES?
*
Your answer
WHAT ARE YOUR BIGGEST STRENGTHS?
*
Your answer
WHAT ARE YOUR BIGGEST STRENGTHS
AS A COUPLE
?
*
Your answer
SESSIONS
*
1 SESSION
2 SESSIONS
4 SESSIONS
8 SESSIONS
12 SESSIONS
3 MONTHS
6 MONTHS
9 MONTHS
1 YEAR
Other:
Please rate your current level of relationship happiness by circling the number that corresponds with
your current feelings about the relationship.
EXTREMELY UNHAPPY
1
2
3
4
5
6
7
8
9
10
EXTREMELY HAPPY
Clear selection
Please make at least one suggestion as to something you could personally do to improve the
relationship regardless of what your partner does.
Your answer
Have you received prior couples counseling related to any of the above problems?
YES
No
Other:
Clear selection
IF YES, WHEN, WHERE, BY WHOM, LENGTH OF TREATMENT, & PROBLEMS TREATED
Your answer
WHAT WAS THE OUTCOME? (CHECK ONE)
VERY SUCCESSFUL
SOMEWHAT SUCCESSFUL
STAYED THE SAME
SOMEWHAT WORSE
MUCH WORSE
Other:
Clear selection
Have either you or your partner been in individual counseling before?
Yes
No
Other:
Clear selection
If so, give a brief summary of the concerns that you addressed.
Your answer
Do either you or your partner drink alcohol to intoxication or take drugs to intoxication?
Yes
No
Other:
Clear selection
If yes for either, who, how often, and what drugs or alcohol?
Your answer
Have either you or your partner struck, physically restrained, used violence against or injured
the other person?
Yes
No
Other:
Clear selection
If yes for either, who, how often, and what happened?
Your answer
Has either of you threatened to separate or divorce (if married) as a result of the current relationship
problems?
Yes
No
Other:
Clear selection
IF YES, WHO?
YOU
PARTNER
BOTH OF YOU
Other:
Clear selection
If married, have either you or your partner consulted with a lawyer about divorce?
Yes
No
Other:
Clear selection
IF YES, WHO?
YOU
PARTNER
BOTH OF YOU
Other:
Clear selection
Do you perceive that either you or your partner has withdrawn from the relationship?
Yes
No
Other:
Clear selection
If yes, which of you has withdrawn?
YOU
PARTNER
BOTH OF YOU
Other:
Clear selection
How frequently have you had sexual relations during the last month?
NO OCCURRENCE
OCCURS RARELY
OCCURS SOMETIMES
OCCURS FREQUENTLY
OCCURS NEARLY ALWAYS
Other:
Clear selection
How enjoyable is your sexual relationship?
EXTREMELY UNPLEASANT
1
2
3
4
5
6
7
8
9
10
EXTREMELY PLEASANT
Clear selection
How satisfied are you with the frequency of your sexual relations?
EXTREMELY UNSATISFIED
1
2
3
4
5
6
7
8
9
10
EXTREMELY SATISFIED
Clear selection
What is your current level of stress (overall)?
NO STRESS
1
2
3
4
5
6
7
8
9
10
HIGH STRESS
Clear selection
What is your current level of stress (in the relationship)?
NO STRESS
1
2
3
4
5
6
7
8
9
10
HIGH STRESS
Clear selection
Rank order the top three concerns that you have in your relationship with your partner (1 being the
most problematic):
Your answer
PLEASE CHOOSE THE OPTIONS INDICATING YOUR LEVEL OF RELATIONSHIP SATISFACTION BEGINNING WITH WHEN YOU MET YOUR PARTNER
NOT SASTISFIED
1
2
3
4
5
VERY SASTISFIED
Clear selection
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