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Couples Therapy Intake

Please complete this on your own, not together. Your partner will receive their own copy.

Your name* (required)Your partner's name* (required)Your email address* (required)Your phone numberIs it safe for us to call you?* (required)

Your relationship

Relationship status* (required)How long have you been together?* (required)How many children are involved?Are you currently living together?* (required)

What's happening

What would you like help with?* (required)

Communication Arguments Trust or infidelity Intimacy Money Parenting differences In-laws or family Life stage or retirement Deciding whether to stay together Separating well

In your own words, what's the difficulty?* (required)How do you think your partner would describe it?* (required)How long has it been like this?* (required)Did something bring you to this point now?

What you want

What are you hoping for?* (required)What do you think your partner wants?* (required)How committed do you feel to working on this?* (required)

Safety and history

This question is asked of both partners separately and confidentially, because it changes what kind of help is appropriate. Nothing you write here is shared with your partner.

Have you ever felt frightened of, or controlled by, your partner?* (required)Have you had couples therapy before?* (required)Is either of you in individual therapy?* (required)

When could you both attend?* (required)

Weekday morning Weekday lunchtime Weekday afternoon Weekday evening Weekend

Leave this field empty