New client questionnaire for couples Counseling

Please complete this form individually. We encourage you to not share your responses with your partner, as we seek your most honest and authentic responses. We will not keep secrets from your partner, but will create opportunities for safe and productive conversations regarding important topics.

It is most effective to complete the full form in one sitting. However, if this is not feasible, you can complete the form in two sittings (but no more or the data will be impacted). If completing in two segments, please "submit" the answers you have completed at the end of your first sitting. Then when you return, fill out name and email address again, and pick up where you left off in answering the questions. Be sure you "submit" again to send the remainder of your answers.

In order for us to best prepare for our work with you, we request this questionnaire be completed 72 hours prior to your first session.  

Name *
What stresses have you and your partner experienced in the last 2 years (check all that apply)
Describe your parents’ relationship to one another (check all that apply)
Do you have concerns about any of the following? (check all that apply)
If yes, check which of the following apply:
Do you experience stress related to any of the following? (select all that apply)