Name
*
First Name
Last Name
Birth Date
MM
DD
YYYY
Phone (Cell/Home/Work)
Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Ethnicity
Religion/Spirituality
Relationship Status
Gender identity
Children and Ages
With whom do you live with?
Emergency Contact Name
First Name
Last Name
Emergency Phone
(###)
###
####
The relationship desires/needs/challenges that have led me to seeking couples coaching is...
How long have you and your partner been together? In what form (e.g., dating, living together, married/engaged/etc.)?
What initially attracted me to my partner is...
The beginning of our relationship was like _____and it lasted for about ______long.
The needs/challenges that seem to be a pattern in our relationship are...
The ways that we are similar and how we are different is...
When there is disconnection/conflict between the two of us, we react/respond by...
When I am angry with my partner, I respond by...
When my partner is angry/frustrated with me, she/he/they/ella respond by...
The strengths and weaknesses I have in resolving conflict are...
My partner’s strengths and weaknesses in resolving conflict are...
Do you enjoy being involved in activities separate from you partner? What do you like to do in those situations?
How comfortable are you if your partner spends free time away from you?
On a scale of 1 to 10, how open are you in expressing your innermost feelings, desires and thoughts to your partner (1=totally closed and 10=totally open)? Explain the rating you give yourself.
The area or topic that it is most difficult to be open with my partner is...
When you could use support or encouragement from your partner, do you get it? How? When your partner wants support of encouragement from you do you feel that you give it? How?
If relevant, describe your sexual relationship. What do you find most satisfying about it? What don’t you like about it?
When do you feel most connected and content in your relationship? When do you feel most unhappy or frustrated?
On a scale of 1 to 10, describe your level of commitment to your relationship (1=not at all, 10= extremely). Explain the rating you give yourself.
On a scale of 1 to 10, how much do you respect your partner (1=not at all, 10=very highly)? What is it about your partner that creates that level of respect in you?
On a scale of 1 to 10, how much do you love your partner (1=not at all, 10=very deeply)? Explain the rating you give yourself.
The ways I have contributed to the challenges in my relationship is...
The tendencies I have and the actions I have taken that have helped create or have added to the difficulties between the two of us is....
If your relationship was a book or a movie, what would it be titled? And how would it end?
Select all of your current habits that apply
Please list any psychiatric or “mental” challenges you have been diagnosed with:
Please list any medical or “physical” challenges that you have been diagnosed with:
Please list any medications you currently take, and what you take them for:
