Marriage Intake FormComplete this form only if you’ve been given the link. Name * First Name Last Name Email * What is the problem that led you to decide to come to couples therapy? * How long have you and your spouse been together? In what form (e.g., dating, living together, married)? * What initially attracted you to your partner? * What was the beginning of your relationship like and how long did this phase last? * How long has it been since things were good between the two of you? What caused things to go downhill after that? * How are the two or you similar and how are you different? * What do you do when there is conflict between the two of you? What does your spouse do? * What do you do when you are angry with him? What does your partner do when angry with you? * What strengths and weaknesses do you have in resolving conflict? What would you say are your partner’s strengths and weaknesses in resolving conflict? * Do you enjoy being involved in activities separate from you partner? What do you like to do in those situations? * On a scale of 1 to 10, how aware or in touch with your emotions are you (1=not at all and 10=extremely)? Explain the rating you give yourself. * On a scale of 1 to 10, how open are you in expressing your innermost feelings, desires and thoughts to your partner (1=totally closed and 10=totally open)? Explain the rating you give yourself. * Is your intimacy where you would like it to be at this time? If not, briefly explain. On a scale of 1 to 10, describe your level of commitment to your relationship (1=not at all, 10= extremely). Explain the rating you give yourself * On a scale of 1 to 10, how much do you still love your spouse (1=not at all, 10=very deeply)? Explain the rating you give yourself. * On a scale of 1 to 10, how much do you respect your partner (1=not at all, 10=very highly)? What is it about him that creates that level of respect in you? * What role have you played in contributing to the problems in your relationship; what tendencies do you have and what actions have you taken that have helped create or have added to the difficulties between you two? * Your information is confidential but will be used during your session.
