Couples Therapy Intake Form

Partner 1 Information

Full Name

Date of Birth

Phone Number

Email

Address

Partner 2 Information

Full Name

Date of Birth

Phone Number

Email

Address

Relationship Information

How long have you been together? Relationship Status Do you have children? If so, please list names and ages. What are your main concerns or reasons for seeking therapy? What goals would you like to achieve during therapy? Have you had couples therapy before? If yes, please describe.