Client Intake Counselling Form (Couples)

Client Intake Counselling Form (Couples)
Name Partner 1

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Address

CityPostcode
Name Partner 2

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Address

CityPostcode
Preferred method of contact:

EmailPhone callTextAll of the above
How long have you been in the relationship?
Have you had couples therapy before?
Do you have children? (If yes, provide their age)
What have you tried in the past to resolve your issues?
What challenges are you facing right now?
Partner 1: What do think your relationship needs the most help with?
Partner 2: What do you think your relationship needs the most help with?
What motivates you to seek counselling now? What are your goals/expectations?
*Your signature below indicates that the information you have provided in this form is accurate and completed best to your knowledge. You have read our Confidentiality Privacy Policy, Terms and conditions and you consent to participate in counselling.
Signature (Partner 1)

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Date

MonthDayYear
Date
Signature (Partner 2)

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Date

MonthDayYear
Date
Should be Empty: