Couples Narrative Intake Form - Private Couples Retreat Program

Each partner should individually complete intake according to comfort level. A thorough response is very helpful to the process but not a prerequisite. All material will be kept confidential. Sharing responses with each other prior to therapy can be very therapeutic for couples who are communicating well and may even remedy the prevalent issue. For acrimonious couples, complete individually and return to therapist at initial appointment.

General Information

Name *

First

Last

Email *

Age

Presenting Issue Information

Where Are You Here Today? *

On a scale of 1 (the best) and 10 (the worst), how badly are you feeling?

Selected Value: 0

On a scale of 1 (the best) and 10 (the worst), how much energy/commitment do you have to the counseling process?*

Selected Value: 0

On a scale of 1 (the best) and 10 (the worst), how much energy/commitment do you think your partner has towards this process?

Selected Value: 0

Couple's Level of Bonding

Below are all variables that impact couple’s level of bonding. Please briefly describe your feelings, thoughts and/or abilities regarding the following:

Being touched *

Touching *

Comfort with showing affection *

Ability to express feelings *

Friends/social relationships *

Sex *

Self-acceptance/love *

Self-advocacy (do you feel confident you can change things) *

Money *

Receiving support *

Stress with job *

Sleeping habits *

Eating habits *

Lingering loss/trauma issues *

Life values *

Life goals *

Centering Questions

How did you feel at that time (about yourself, your partner)? *

When did issues begin? *

What is your hypothesis of the problem? *

What external stressors are impacting your relationship? (e.G., illness, death, $, job) *

What internal stressors are impacting your relationship? (e.G., age, loneliness, self-esteem, depression) *

What are your beliefs about partner’s love for you? *

What are your beliefs about partner’s level of commitment to you? *

How would you like to be treated differently by your partner? *

How do you want to be different in your relationship? *

What has hurt you the most in this relationship? *

What is the worst thing you have done to hurt your partner? *

Do you feel you have let your partner down? How? *

How do you treat your partner when you feel bad about yourself? *

Does your partner ever remind you of someone in your life? Why? When? *

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