Couple Information Form Couple Information Form Client Name* PhoneAddress City State Zip Occupation Business PhoneEmployer Name Other Insurance Coverage Yes No Other Insured’s Name (last name, first name, middle initial) Other Insured’s Policy or Group # Sex Birth Date MM slash DD slash YYYY AgeMarital Status Dating/Engaged Married Years Previous Marriages? Yes No If yes, How many? Education High School College Degree Years Years Other Training Referred by Partner/Spouse InformationName Address (If different from above) Occupation Business PhoneEmployer Name Birth Date MM slash DD slash YYYY Age Education High School College Degree Years Years Other Training Previous Marriages? Yes No If yes, How many? ChildrenName Age Sex Name Age Sex Name Age Sex Mental/Relational Health InformationHave either of you received individual counseling or mental health treatment before? Yes No If yes, who received treatment and what was the treatment for?Do either of you now or have you in the last 5 years had a substance abuse problem such as alcohol, drugs or prescription drugs? Yes No Please DescribeHave either of you ever had a severe emotional upset or trauma? I.e., sexual abuse, emotional abuse, loss of loved one, post traumatic stress disorder, etc. Yes No Please DescribeHave you participated in marital/relationship counseling before? Yes No If you have, for how long and what was the outcome?Rate your commitment to this relationship/marriage? Husband/Partner 1: Low 1 2 3 4 5 6 7 8 9 10 High Wife/Partner 2: Low 1 2 3 4 5 6 7 8 9 10 High If you could change only one thing about your partner/spouse that would make a huge difference in your relationship, what would it be? Husband/Partner 1 Wife/ Partner 2 Religious Background Husband (Partner 1) Do you believe in God? Yes No Uncertain Do you attend church? Yes No How often per month? 0 1 2 3 4 5 6 7 8 9+ Are you saved? Yes No Not sure What that means Denominational Preference Where do you attend? Baptized? Yes No When? How frequently do you read the bible? Never Occasionally Often Do you have regular devotions together? Yes No Wife: (Partner 2) Do you believe in God? Yes No Uncertain Do you attend church? Yes No How often per month? 0 1 2 3 4 5 6 7 8 9+ Are you saved? Yes No Not sure What that means Denominational Preference Where do you attend? Baptized? Yes No When? How frequently do you read the bible? Never Occasionally Often Do you have regular devotions together? Yes No Reason for Seeking CounselingWhat problem or issue are you seeking counseling for?What have you tried to do about it?What specifically would you like us to focus on? (What are your expectations?)What brings you here currently?Is there any other information I should know?CAPTCHA
