Couples Counselling form

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Please review the couples counselling preparation form below, prior to attending your couples therapy.

Couples Counselling forms

Name(Required)

First Name Last Name

D.O.B(Required)

D.O.B

Email(Required)

Enter Email Confirm Email

Please use the drop-down to select the therapist you're booked in with.(Required)

Please use the drop-down to select the therapist you're booked in with.

Your Address(Required)

Your Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

G.P. Name(Required)

G.P. Name

Address(Required)

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

G.P. Phone(Required)

G.P. Phone

Goals of therapy(Required)

Goals of therapy

Partners name(Required)

Partners name

Status of relationship(Required)

Status of relationship

Length of time in this relationship? Married couples: How long were you both dating prior to getting married?(Required)

Length of time in this relationship? Married couples: How long were you both dating prior to getting married?

Previous relationships (long term) how you meet, length of time, who broke up the relationship and why:

Length of time in this relationship? Married couples: How long were you both dating prior to getting married?(Required)

Length of time in this relationship? Married couples: How long were you both dating prior to getting married?

Have you had couples’ therapy or individual therapy before, if so please identify what you liked or disliked?(Required)

Have you had couples’ therapy or individual therapy before, if so please identify what you liked or disliked?

Current relationship history: How did you both meet? What first attracted you to your partner?(Required)

Current relationship history: How did you both meet? What first attracted you to your partner?

How would you describe your history from the start of your relationship to the present moment?(Required)

How would you describe your history from the start of your relationship to the present moment?

What are important beliefs for you, that you both have in common? What beliefs do you not share?(Required)

What are important beliefs for you, that you both have in common? What beliefs do you not share?

What did you envisage the relationship to be, when you first met? Has this changed and if so, how?(Required)

What did you envisage the relationship to be, when you first met? Has this changed and if so, how?

In what ways do you hope that treatment such as, if appropriate, counselling or therapy could help you?(Required)

In what ways do you hope that treatment such as, if appropriate, counselling or therapy could help you?

List all the changes you need to make to create the relationship you want(Required)

List all the changes you need to make to create the relationship you want

What are some of the things you would need to see that will help you to know you’re on the right track with the changes your making?(Required)

What are some of the things you would need to see that will help you to know you’re on the right track with the changes your making?

What traits does your partner have that you find challenging? Which of your traits does your partner find challenging?(Required)

What traits does your partner have that you find challenging? Which of your traits does your partner find challenging?

How do you resolve conflicts? How does your partner resolve conflicts?(Required)

How do you resolve conflicts? How does your partner resolve conflicts?

Any previous or current issues of domestic violence?(Required)

Any previous or current issues of domestic violence?

Do either you or your partner currently have an issue with alcohol or drugs?(Required)

Do either you or your partner currently have an issue with alcohol or drugs?

How easy or difficult do you find it to express your feelings, thoughts, desires and values to your partner?(Required)

How easy or difficult do you find it to express your feelings, thoughts, desires and values to your partner?

Mother: Please describe your relationship.(Required)

Mother: Please describe your relationship.

Father: Please describe your relationship.(Required)

Father: Please describe your relationship.

Siblings: Please describe your relationship(s)(Required)

Siblings: Please describe your relationship(s)

Were there any important changes, for example, moves or any other significant events, during childhood? Including any separations from the family or parental divorce. Please give approximate ages and details.(Required)

Signature(Required)

Signature: I confirm the information provided is accurate and I agree to the terms & conditions.

Comments

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