Intake

IMPORTANT INSTRUCTIONS

Each partner complete separately and confidentially, return to therapist at least 24 hours prior to appointment.

Intake Forms and Therapist Reports are not permissible in court. If you need legal documentation, consult an attorney, advocate or forensic psychological testing agency.

This intake is designed for lots of different relationship situations. It’s purpose is to help each of you gain more clarity regarding identification of the problem and rule out or detect possible deeper dynamics that could be underlying your persistent conflict and bonding patterns.

Disclaimer: Not all relationships are safe. Whether it be emotionally, physically, sexually, financially or psychologically, if you don’t feel comfortable sharing your thoughts at this time with your partner, please don’t.

Step 1 of 11

Name

First Last

Email(Required)

Date of Birth

MM slash DD slash YYYY

MOOD & MOTIVATION

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

1	2	3	4	5	6	7	8	9	10

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

1	2	3	4	5	6	7	8	9	10

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

1	2	3	4	5	6	7	8	9	10

On your worst day, what best describes your relationship to suffering? Choose the one that best fits you.

Stoic: I’m tough. I internalize pain, I don’t like to complain or be a burden on others. I have a high pain tolerance.

Martyr: I’m sensitive. I tend to get attention by demonstrating my suffering and feeling wronged by others..

Logical: I like to rely on data, logic and less on emotional reactivity. I’m not always sure of what I’m feeling.

Emotional: I feel everything intensely. It can be a challenge to stay focused on anything else when I’m upset. I’m sad, depressed or mad.

What best describes your objective?

Proactively set goals and troubleshoot challenges with communication.

Decide if we are compatible.

Resolve our current issues and stay together.

Resolve our issues and decide what’s best, to deepen, reignite or decide about the relationship.

Leave the relationship on the best terms possible.

Focus on strategies to deal with a particular pain point, such as an affair, sexuality, financial, health, work, external stressors, losses, parenting.

When did you or your partner stop demonstrating affection and respect?

We’ve always demonstrated affection and respect. It hasn’t stopped.

We’ve never had a consistent demonstration of affection or respect.

Due to an event

Due to increasing resentment around

Other

When did you or your partner stop demonstrating affection and respect? - Due to increasing resentment around

When did you or your partner stop demonstrating affection and respect? - other

What is your hypothesis for the issue in your relationship, the “Why”? This information is integrated into the Therapist Report.

Communication

How well do you resolve misunderstandings?

Excellent, we are efficient.

Good, sometimes it takes time, but we get there.

Bad, we repress, avoid or fight about things.

Resentment & Defensiveness

On a scale of 1-10 (10 highest, 1 lowest)

	1	2	3	4	5	6	7	8	9	10
How much resentment do you feel towards your partner?
How much resentment do you think they feel towards you?
How defensive do you feel towards your partner when they give you feedback about you?
How defensive do you feel your partner is towards you when you provide them feedback?

Gut Check

It’s your right and responsibility to determine and hold onto your true desires. It’s essential that both partners are authentic to move on well and decrease conflict. Even if the answer isn’t an easy yes, understanding what you really want can help partners respect each other and be more clear towards next steps. If more than one reply resonates with you, apply a percentage on how much it resonates.

Is this what I really want?

Yes, I’m sure because

Yes, I’m sure, but first I need to figure out

Maybe, I need to find out

I think so, but I need some time to first determine

No, but I want my partner to break up with me.

No, but I’m scared to be alone.

Is this what I really want? - more info

When did you change the way you felt sexually about your partner?

I’ve never changed. I’ve always enjoyed expressing myself sexually with my partner.

We’ve never had an easy time expressing ourselves sexually with each other.

Due to an event

Due to increasing resentment around

Other

When did you change the way you felt sexually about your partner? - more info

Do You:

Feel that I owe sex to my partner or they will get mad.

Enjoy expressing myself sexually. My desire is mine and I share it with my partner. I feel free.

Have a hard time understanding my desire.

Struggle to feel sexual with my partner.

Other

Do You: - more info

Did you receive positive guidance or modeling regarding sex as a child and/or adolescent?

Yes, I had mostly positive models and guidance.

No, I had really bad modeling and shameful fear based messages via religion and/or parents.

Neutral, I received no modeling or guidance. Sex existed in a vacuum.

Have you experienced any sexual “bad experiences,” including, trauma, aggression, humiliation, or other negative experiences in childhood/adolesence or prior romantic relationships?

No, thankfully I haven’t.

Yes, and I received help to resolve associated traumatic feelings and thoughts.

Yes, and I didn’t receive any help to resolve associated traumatic feelings and thoughts.

Have you experienced any sexual “bad experiences,” including, trauma, aggression, humiliation, or other negative experiences in your current relationship?

No, thankfully I haven’t.

Yes, and I received help to resolve associated traumatic feelings and thoughts.

Yes, and I didn’t receive any help to resolve associated traumatic feelings and thoughts.

Additional thoughts related to sex and your current situation?

TRUST

When you tell yourself that you’re going to do something, do you believe that you’ll follow through?

Yes. I know my own mind and how to follow through.

Sometimes yes, sometimes no. I’m inconsistent and unsure often.

No, I don’t trust my own words. I usually doubt my feelings, thoughts and plan of action.

When your partner tells you that they’re going to do something, do you believe that they’ll follow through?

Yes. My partner consistently follows through on his word with their actions. They are reliable

Sometimes yes, sometimes no. They are inconsistent and unsure, sometimes backing out of plans.

No, I don’t trust their word. They don’t follow up with actions and contradict their previous statements.

Does your partner trust you?

Yes. They trust me easily.

Sometimes. They can get insecure and need reassurance sometimes.

No. They struggle to trust me consistently for good reason. It’s an unresolved issue.

No. They struggle to trust me consistently for no true reason. It’s an unresolved issue.

Additional thoughts about trust?

Were you a good listener at the beginning of your relationship?

Yes, I listened more closely.

No, I was pretty much the same.

Are you a good listener now?

Yes. I enjoy listening to my partner and reflect back well. I remember later as well.

Sometimes. I can easily get distracted and overwhelmed, but I care.

No. I’m not that engaged as a listener. I’m often thinking about myself.

No. I tune out my partner and am defensive, because I often feel resentment towards them.

Is your partner a good listener?

Yes. My partner enjoys listening to me. They recall previous things I’ve said and appreciate me.

Sometimes. They can easily get distracted and overwhelmed about their own life, but I know they care.

No. My partner is not that engaged as a listener. They are often thinking about themselves.

No. My partner doesn’t listen or respect me, they are passive aggressive and defensive.

What’s Been Good in Your Life?

Positive influences impacting your relationship to Love Sex Trust

What’s Been Sad: Grief, Anger & Loss History

(impacting your relationship to Love Sex Trust)

Event(s) 0-3

Impact Beliefs-Behaviors-Heart 0-3

Event(s) 4-6

Impact Beliefs-Behaviors-Heart 4-6

Event(s) 7-10

Impact Beliefs-Behaviors-Heart 7-10

Event(s) Adolescence

Impact Beliefs-Behaviors-Heart Adolescence

Event(s) Young Adulthood

Impact Beliefs-Behaviors-Heart Young Adulthood

Event(s) Adulthood

Impact Beliefs-Behaviors-Heart Adulthood

Early Life Attachments: Family of Origin

Did you feel they loved you? Liked you?

Father

Yes	No	Maybe	N/A

Father Name

Mother

Yes	No	Maybe	N/A

Mother Name

Step Father

Yes	No	Maybe	N/A

Step Father Name

Step Mother

Yes	No	Maybe	N/A

Step Mother Name

Sibling 1

Yes	No	Maybe	N/A

Sibling 1 Name

Sibling 2

Yes	No	Maybe	N/A

Sibling 2 Name

Sibling 3

Yes	No	Maybe	N/A

Sibling 3 Name

Friend 1

Yes	No	Maybe	N/A

Friend 1 Name

Friend 2

Yes	No	Maybe	N/A

Friend 2 Name

Friend 3

Yes	No	Maybe	N/A

Friend 3 Name

Teacher 1

Yes	No	Maybe	N/A

Teacher 1 Name

Teacher 2

Yes	No	Maybe	N/A

Teacher 2 Name

Teacher 3

Yes	No	Maybe	N/A

Teacher 3 Name

Enemy 1

Yes	No	Maybe	N/A

Enemy 1 Name

Enemy 2

Yes	No	Maybe	N/A

Enemy 2 Name

Enemy 3

Yes	No	Maybe	N/A

Enemy 3 Name

Relationship 1

Yes	No	Maybe	N/A

Relationship 1 Name

Relationship 2

Yes	No	Maybe	N/A

Relationship 2 Name

Relationship 3

Yes	No	Maybe	N/A

Relationship 3 Name

In Good Faith Assessment: Relationship Decision Making

A. Am I being of “good faith”?

Do I care for the vulnerabilities in my partner and try to not use them to my advantage?

A1. Is my motive to be transparent, telling the truth to enhance our relationship to increase love and understanding?

Yes

A2. Is my motive to be manipulative, making it hard for my partner to be understood, making them feel guilty, confused, taking advantage of their vulnerabilities, playing the part of a victim to gain an advantage or feel powerful over them?

Yes

B. Do I feel my partner is of “good faith”?

Do they care for my vulnerabilities and not try to use them for their advantage?

B1. Is their motive to tell the truth to enhance our relationship to increase love and understanding?

YES

B2. Is their motive to be manipulative, making it hard to be understood, making me feel guilty, confused, taking advantage of my vulnerabilities, playing the part of a victim to gain an advantage or feel powerful over me?

YES

C. Past Relationship History

C1. Have I often been argumentative, difficult or manipulative in past or other relationships?

YES

C2. Do you feel your partner was often argumentative, difficult or manipulative in past or other relationships?

YES

D. “In Bad Faith,” Negative Communication Manipulative Techniques

On a scale of 0-5, 0=not at all, 5= all the time, which techniques do you use with your partner? Answer according to the tactics you use. Tally final score at bottom for yourself.

	0	1	2	3	4	5
Narcissistic projection: Accusing someone of a negative character trait or manipulative behavior that you are actually doing to them.
Pathologizing, Assigning the Person to be an Unreliable Narrator: Indicating someone has a disorder or entrenched negative, maladaptive, anti-social traits. Assessing character rather than behavior as the source of a person’s motives for behavior. Dismisses their credibility. This gets confusing because a narcissistically defended person often pathologizes others via narcissistic projection (see above).
Obfuscation: Convoluting a response, making it confusing and difficult to follow, blaming the other for confusion.
Bait and Switch also Gaslighting: Acting one way and then switching to negate the earlier reality. Telling someone their recollection of events is categorically wrong.
Moving the Goalposts: Changing the criteria for something once someone has reached the initial request.
Hoovering, Love Bombing, Breadcrumbing, Ghosting, Negging: These are all forms of intermittent reinforcement, receiving lots of positive attention upfront and then sporadic withdrawal, change in attitude/response, intermittent ambivalence (“I like you, I’m now not so sure”), that doesn’t follow a specific pattern. Making the other person prove their attraction, adoration, loyalty or desire for you.
Feigned Responses, Sarcasm, Manipulation, Threatening Self Harm, Acting: Acting one way in the moment but internally not believing in what you are saying.
Virtue Signaling: Acting as if you’re actually virtuous and misunderstood, a victim, when someone is pointing out how you’ve hurt them. Can also present themselves as a “worn thin but loyal” to their problematic partner.
Incurious: Not interested in investigating one’s less conscious motives even when pointed out.
Discrediting the Source, Dismissing, Intellectualization, Placating: Using tactics to question the credibility or validity of a person’s experience for a sense of control, decreases the other person’s confidence in trusting their own feelings and thoughts over time.
Spiritual Bypassing, Gaslighting Yourself with Religion: Using dogma or doctrine to “bypass” facing your own opinions, trauma pain or criticism of a family system by adhering to principles or rules that signal virtue.

On a scale of 0-5, 0=not at all, 5= all the time, which techniques does your partner use? Answer according to the tactics your partner use. Tally final score at bottom for your partner.

	0	1	2	3	4	5
Narcissistic projection: Accusing someone of a negative character trait or manipulative behavior that you are actually doing to them.
Pathologizing, Assigning the Person to be an Unreliable Narrator: Indicating someone has a disorder or entrenched negative, maladaptive, anti-social traits. Assessing character rather than behavior as the source of a person’s motives for behavior. Dismisses their credibility. This gets confusing because a narcissistically defended person often pathologizes others via narcissistic projection (see above).
Obfuscation: Convoluting a response, making it confusing and difficult to follow, blaming the other for confusion.
Bait and Switch also Gaslighting: Acting one way and then switching to negate the earlier reality. Telling someone their recollection of events is categorically wrong.
Moving the Goalposts: Changing the criteria for something once someone has reached the initial request.
Hoovering, Love Bombing, Breadcrumbing, Ghosting, Negging: These are all forms of intermittent reinforcement, receiving lots of positive attention upfront and then sporadic withdrawal, change in attitude/response, intermittent ambivalence (“I like you, I’m now not so sure”), that doesn’t follow a specific pattern. Making the other person prove their attraction, adoration, loyalty or desire for you.
Feigned Responses, Sarcasm, Manipulation, Threatening Self Harm, Acting: Acting one way in the moment but internally not believing in what you are saying.
Virtue Signaling: Acting as if you’re actually virtuous and misunderstood, a victim, when someone is pointing out how you’ve hurt them. Can also present themselves as a “worn thin but loyal” to their problematic partner.
Incurious: Not interested in investigating one’s less conscious motives even when pointed out.
Discrediting the Source, Dismissing, Intellectualization, Placating: Using tactics to question the credibility or validity of a person’s experience for a sense of control, decreases the other person’s confidence in trusting their own feelings and thoughts over time.
Spiritual Bypassing, Gaslighting Yourself with Religion: Using dogma or doctrine to “bypass” facing your own opinions, trauma pain or criticism of a family system by adhering to principles or rules that signal virtue.

Total Score Me

Total Score Partner

F. TRUST

Physical/Health or Age Related

Would you like to share anything? How did this shape you in relationships?

Love-ability

Would you like to share anything? How did this shape you in relationships?

Identity

Would you like to share anything? How did this shape you in relationships?

Attractiveness

Would you like to share anything? How did this shape you in relationships?

Career/Professional/Financial

Would you like to share anything? How did this shape you in relationships?

Sexuality Identity

Would you like to share anything? How did this shape you in relationships?

Sexual Performance

Would you like to share anything? How did this shape you in relationships?