Couples Intake Questionnaire


Couples Intake Questionnaire




Full name:
Email address:

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

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

3. What initially attracted you to your partner?

4. What was the beginning of your relationship like and how long did this phase last?

5. What happened that first caused you to feel disillusioned with your partner? Did this
lead to any changes in your relationship?

6. How long has it been since things were good between the two of you? What caused
things to go downhill after that?

7. How are the two or you similar and how are you different?

8. What do you do when there is conflict between the two of you? What does your
partner do?

9. What do you do when you are angry with him? What does your partner do when
angry with you?

10. What strengths and weaknesses do you have in resolving conflict? What would you
say are your partner’s strengths and weaknesses in resolving conflict?

11. Do you enjoy being involved in activities separate from you partner? What do you
like to do in those situations?

12. How comfortable are you if your partner spends free time away from you?

13. Do you have relationships with other people that create conflict with your partner,
and if so, why?

14. 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.

15. 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.

16. What is the area or topic that it is most difficult for you to open with your partner
about? Why?

17. When you could use support or encouragement from your partner, do you get it?
How? When your partner wants support of encouragement from you do you feel that
you give it? How?

18. Describe your sexual relationship. What do you find most satisfying about it? What
don’t you like about it? How has your sexual relationship changed since you were first
together?

19. When do you feel most content in your relationship? When do you feel most
unhappy or frustrated?

20. 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.

21. On a scale of 1 to 10, how much do you still love your partner (1=not at all, 10=very
deeply)? Explain the rating you give yourself.

22. 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?

23. 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?

24. If your relationship was a book or a movie, what would it be titled? And how would it
end?