Couples Therapy Intake Form
Personal Information
Partner 1 Full Name
Partner 2 Full Name
Partner 1 Birthdate
Partner 2 Birthdate
Phone Number
Email Address
Address
Relationship Details
How long have you been together?
Marital Status
Married
Unmarried
Separated
Other
Do you have children together?
Yes
No
Previous Counseling (individual or together)
Main Concerns
What brings you to couples therapy?
What goals do you hope to achieve?
Additional Information
Anything else you would like the therapist to know?