Couples Counselling Form

Please review the couples counselling preparation form below, prior to attending your couples therapy.

Step 1 of 3

We request this is completed 24 hours before your session, which allows us to prepare for your session however If you feel uncomfortable filling out certain parts of this form, please enter N/A.

Your details

Date(Required)

Name(Required)

First Last

Date of birth(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Email(Required)

G.P. Phone number(Required)

G.P. Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Therapist name(Required)

Your relationship

Partner’s Name(Required)

What are your current concerns (please bullet point this)?(Required)

Status of your relationship. Length of time in this relationship?(Required)

Married couples: How long were you both dating prior to getting married? Did you live together before marriage, if so, how long for?

Previous relationships (long term) how you meet, length of time, who broke up the relationship and why:

Have you had couples’ therapy or individual therapy before, if so please identify what you liked or disliked?(Required)

Current relationship history: How did you both meet? What first attracted you to your partner?(Required)

How would you describe your history from the start of your relationship to the present moment?(Required)

What are important beliefs for you, that you both have in common? What beliefs do you both not share?(Required)

What did you envisage the relationship to be, when you first met? Has this changed and if so, how?(Required)

What kind of relationship do you want to be in? What do you need to do to make that happen?(Required)

List the barriers you bring to the relationship you want(Required)

List all the changes you need to make to create the relationship you want(Required)

What are some of the things you would need to see that will help you to know you’re on the right track with the changes your making?(Required)

What do you need to let go off for you to be the partner you want to be?(Required)

What traits in your partner do you like and why?(Required)

What traits does your partner have that you find challenging? Which of your traits does your partner find challenging?(Required)

How do you resolve conflicts? How does your partner resolve conflicts?(Required)

Any previous or current issues of domestic violence?

If yes, please provide details(Required)

Do either you or your partner currently have an issue with alcohol or drugs?(Required)

What strengths do you implement to support resolving differences? What strengths does your partner have?(Required)

Do you try and resolve conflicts and if so how? Are these successful? Does your partner notice?(Required)

How easy or difficult do you find it to express your feelings, thoughts, desires and values to your partner?(Required)

If you require support by your partner, do you receive this and how? If your partner needs your support, do you offer this and how?(Required)

Your details

Your relationship

Family history

Get In Touch

71 Vyse Street, Jewellery Quarter, Birmingham, B18 6EX

Email Company

Time Open

We Are Support 24/7

Partners

The Counselling Clinic

Online Counselling Clinic