Marriage Counseling Intake Form
Contact Information
Partner 1 Full Name
Partner 2 Full Name
Contact Number
Email Address
Address
Background Information
Date of Birth (Partner 1)
Date of Birth (Partner 2)
Occupation (Partner 1)
Occupation (Partner 2)
Relationship Status
Married
Engaged
Long-term partners
Other
How long have you been together?
Do you have children?
Yes
No
If yes, please provide ages:
Reasons for Seeking Counseling
Please describe the primary reasons for seeking counseling.
What are your goals for counseling?
Previous Counseling Experience
Have you attended counseling before (individually or as a couple)?
Yes
No
If yes, when and what was your experience?
Additional Information
Is there any additional information you would like to share?