Couple Information Form Couple Information Form Client Name*PhoneAddressCityStateZipOccupationBusiness PhoneEmployer NameOther Insurance CoverageYesNoOther Insured’s Name (last name, first name, middle initial)Other Insured’s Policy or Group #SexBirth Date Date Format: MM slash DD slash YYYY AgeMarital StatusDating/EngagedMarriedYearsPrevious Marriages?YesNoIf yes, How many?EducationHigh SchoolCollegeDegreeYearsYearsOther TrainingReferred byPartner/Spouse InformationNameAddress (If different from above)OccupationBusiness PhoneEmployer NameBirth Date Date Format: MM slash DD slash YYYY AgeEducationHigh SchoolCollegeDegreeYearsYearsOther TrainingPrevious Marriages?YesNoIf yes, How many?ChildrenNameAgeSexNameAgeSexNameAgeSexMental/Relational Health InformationHave either of you received individual counseling or mental health treatment before?YesNoIf 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?YesNoPlease 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.YesNoPlease DescribeHave you participated in marital/relationship counseling before?YesNoIf 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 HighWife/Partner 2: Low 1 2 3 4 5 6 7 8 9 10 HighIf 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 1Wife/ Partner 2Religious Background Husband (Partner 1) Do you believe in God?YesNoUncertainDo you attend church?YesNoHow often per month? 0 1 2 3 4 5 6 7 8 9+Are you saved?YesNoNot sureWhat that meansDenominational PreferenceWhere do you attend?Baptized?YesNoWhen?How frequently do you read the bible?NeverOccasionallyOftenDo you have regular devotions together?YesNoWife: (Partner 2) Do you believe in God?YesNoUncertainDo you attend church?YesNoHow often per month? 0 1 2 3 4 5 6 7 8 9+Are you saved?YesNoNot sureWhat that meansDenominational PreferenceWhere do you attend?Baptized?YesNoWhen?How frequently do you read the bible?NeverOccasionallyOftenDo you have regular devotions together?YesNoReason 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
