Creating a Brighter Future Together
Couples Therapy Questionnaire

                                              COUPLES QUESTIONNAIRE INTAKE


Today's Date:______________
Name:__________________________________
Street Address:____________________________________________________________
City:____________________________   State:_______        Zip Code: _________
Telephones: _______________________(h)    __________________________(w)  
                  _________________________(cell)  
Email: ____________________________________________________________

1. What is the problem that led you to decide to come to therapy?




2. How long have you and your partner been together?         In what form? (i.e., dating, living together, married, other)

3. What initially attracted you to your partner?




4. How was the decision to live together (or not), or to marry made?



5. Do you have chldren? If so, please name them with their current ages.




6. Do you have any pets? Please be specific, i.e, types, names, ages.


7. What was the very beginning of your relationship like?




   How long did this phase last?

8. What was your first disillusionment? What happened and how did you resolve it?




   Did this lead to any changes in your relationship?



9. When did you first become aware of significant differences between the two of you?
 



   How are the two of you similar?



   How are you different?




10. What do you do when there is conflict between the two of you?





   What does your partner do?





11. What do you do when you are angry?






   What does your partner do when angry?






12. What strengths do you have that support resolving differences?







    What strengths does your partner have?





13. Do you spend time alone?                      Do you enjoy your free time?

      Does this create conflict in your relationship?

14. Do you have separate friendships with people who are not mutual friends? 
       Does this create conflict in your relationship?


15. Are you comfortable doing activities away from your partner?           What do you like to do?

    
     How comfortable are you with your partner spending time away from you?


16. On a scale of 1 to 10, how open are you in expressing your innermost wants, thoughts, desires, and feelings to your partner? (1 is totally closed  and 10  is totally open.)

17. When you feel like you want support or encouragement from your partner, do you get it?          How?
  

      When your partner wants support or encouragement from you, do you feel that you give it?        How?


18. Do you support your partner's development as an individual?         How? (Give an example.)



     Do you support his/her growth as an individual even when you don't agree?        How? (Give an example.)



19. Describe your sexual relationship. 


      What do you find most satisfying about it?



    What do you find least satisfying about it?



    How has your sexual relationship changed since you were first together?\



20. What is one thing that you wish were different about your sexual relationship?




21. When do you feel most gratified in your relationship?




     When do you feel most frustrated in your relationship?




22. Do the two of you have joint commitments to goals, projects, work, or social causes?


       Does this add or detract from the bond between you?

23. If your relationship was a movie, drama or book, what would it be titled?

     How would it end?


24. What are your primary goals for couple therapy?




25. What would you be willing to invest to accomplish these?
     
       * Time
       * Energy
       * Money
       * All of the above
       * Nothing

26. What do you anticipate your partner would be willing to invest to accomplish his/her primary goals?

       * Time
       * Energy
       * Money
       * All of the above
       * Nothing

27. How did you hear about the Center for Relational Therapy and Margo Steinfeld?


28. Which modality(ies) would interest you?

       * Private couple therapy
       * Couples Group Therapy
       * Individual Group Therapy
       * Individual Therapy

29. Anything else you feel is important to say? Please use blank sides if needed.


     

 

             Thank you for taking this time to consider the possibility to create the relationship of your dreams.


               

                                                                                                                                               Margo Steinfeld, LCSW, MA, CGP
                                                                                                                                               Psychotherapist/ Relationship Specialist






                                                                          [Adapted from Copyright: 2006The Couples Institute]






 





 

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