Form templates / Mental Health & Therapy
Couples Therapy Intake Form
A couples therapy intake form has to be answerable honestly by two people who may not agree about anything, including why they're coming.
For therapists, counsellors and mental-health practices.
Each partner fills it in separately, and that's the design
A single joint form gets answered by whichever partner is more motivated, in words the other might not endorse. What you want is each person's own account - which routinely differ in ways that are the most useful information you'll get before session one.
So this form is designed to be sent to both and completed separately. It also asks about safety individually, because a form completed together in the same room cannot safely surface coercion or abuse - and that is the one thing you must know before doing couples work at all.
The cost of asking twice
Chasing details is invisible work: it doesn't appear on any invoice, but it eats the first week of every new relationship. Worse, it happens at exactly the moment a client is deciding whether you are organised.
This template front-loads it. One link, one pass, everything you need to open the file - and a written record of what they told you.
Ask gently, and hold it carefully
A first contact form in this field is often written by someone who has been putting it off for months. Short, plain and unintimidating matters more than thorough - you can ask the rest once there's a relationship.
What it must not do is feel surveilled. These pages carry no analytics, no third-party scripts and no cookie banner, and responses go only to the address you nominate.
Nothing to install, nothing to learn
Your clients get a link. No account, no app, no cookie banner between them and the first question. The page is a single file that loads in one request, which on a phone on mobile data is the difference between a submitted form and a closed tab.
Edit it like a document, publish like a link
Add questions, remove questions, change the order and the wording, set your accent colour. When you save, the form is live at its own address - share it by link, QR code or a button on your site, and read the answers in your dashboard.
What this template asks
- Your name
- Your partner's name
- Your email address
- Your phone number
- Is it safe for us to call you?
- Relationship status
- How long have you been together?
- How many children are involved?
- Are you currently living together?
- What would you like help with?
- In your own words, what's the difficulty?
- How do you think your partner would describe it?
- How long has it been like this?
- Did something bring you to this point now?
- What are you hoping for?
- What do you think your partner wants?
- How committed do you feel to working on this?
- Have you ever felt frightened of, or controlled by, your partner?
- Have you had couples therapy before?
- Is either of you in individual therapy?
- When could you both attend?
More Mental Health & Therapy forms
Questions
Should both partners complete this?
Yes, separately - send the link to each of them. Comparing two accounts of the same relationship is the point, and a jointly-filled form can't ask about safety.
What if one partner discloses abuse?
Couples work is generally contraindicated where there is coercive control or violence. That's why the safety question is here and why each partner answers alone - follow your own professional guidance on what to do next.
Can I add or remove questions?
Yes - every question here is a starting point. Add your own, delete what doesn't apply, reorder by dragging, and make anything required or optional. Saving publishes the change immediately.
Where do the answers go?
Into your dashboard, where you can read, filter and export them as a spreadsheet. You can also have every response emailed to you the moment it arrives, or as a daily or weekly digest.
Do I need a website?
No. Every form gets its own link you can paste into an email signature, a text message, a QR code or a social profile. If you do have a site, you can link to it from anywhere on it.
Is this confidential enough for therapy enquiries?
Pages are encrypted in transit and responses stay in your account, going only to the recipients you choose. Keep the form to what you need to make contact, say clearly that it is not for emergencies and where to go instead, and check your professional body's guidance on electronic records.
Publish your couples therapy intake form today
Start from this template and change anything you like. Free to begin.