Couple counselling intake form
Name Partner 1
First Name
Last Name
Name Partner 2
First Name
Last Name
Phone Number Partner 1
-
Area Code
Phone Number
Phone Number Partner 2
-
Area Code
Phone Number
Partner 1 Email address
example@example.com
Partner 2 Email address
example@example.com
Address
City
Postcode
How long have you been in the relationship?
Have you had couples therapy before?
What have you tried in the past to resolve your issues?
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?
Submit
Should be Empty: