Couples Counselling form

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

Couples Counselling forms

DD slash MM slash YYYY
Please use the drop-down to select the therapist you're booked in with.
Your Address(Required)
Your Address
G.P. Name(Required)
G.P. Name
G.P. Phone
✓ Valid number ✕ Invalid number
✓ Valid number ✕ Invalid number
Goals of therapy
Partners name
Status of relationship
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?
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?
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?
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?
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?
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?
Any previous or current issues of domestic violence?
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?
Mother: Please describe your relationship.
Father: Please describe your relationship.
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.
Signature: I confirm the information provided is accurate and I agree to the terms & conditions.
This field is for validation purposes and should be left unchanged.
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