Adult/Couple Intake Form This is a confidential questionnaire that will provide me with information that will be helpful in coaching or therapy. If there are questions that you would rather not answer, leave them blank. You will receive an email copy of your form upon completion that you can print out for yourself.Name* First Last Birth Date* MM slash DD slash YYYY Home PhoneWork PhoneCell PhoneAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Referral Source Emergency Contact Emergency Contact PhoneEmployer Today's Date* MM slash DD slash YYYY What made you seek therapy/coaching at this time?If therapy/coaching is successful, how will you and/or your life be different? What are your therapy/coaching goals?Name, ages and brief description of people living in your home:Education (list degrees and courses of study):Job History (name of employer, dates, position, degree of satisfaction):Health History: Illnesses, Injuries, SurgeriesHealth History: Current health issuesHealth History: Current medications, reason, and name of prescribing physicianHealth History: Do you have a problem with: alcohol drugs food cravings weight gain/loss body image insomnia PMS/moods sexual issues depression anxiety/PTSD anger shame/shyness social anxiety focus motivation Family of Origin: Names, ages, brief descriptions:You can draw the family tree on a sheet of paper and bring with you to the next session if you prefer.What kind of relationship did you have with your mother?What kind of relationship did you have with your father?What kind of relationship did you have with your siblings?What kind of relationship did you have with other significant members (stepparents, grandparents etc)?Important Events in Childhood:Important Events in Teenage Years:What was the mood of the house?Relationship History (choose the most important relationships):Names, dates, brief descriptions of partner(s) and basic qualities of the relationship:What are your intimacy issues, patterns, and trends?Trauma History:Have you ever been sexually or physically abused? By whom? When? How long have you known?What Significant Losses have you experienced? When?Have you ever made a suicide attempt? Please give details:Describe yourself, including positive and negative traits:Current Marriage/Relationship:How long together? How long married? What was your initial attraction to your partner?What do you currently like or appreciate about your partner?What are the strengths or foundational aspects of your relationship?What are the weaknesses of your relationship? What changes do you want to see?Which of these issues are major sources of conflict for YOU: money parenting sex/quantity sex/quality in-laws household tasks power/control communication different values respect trust other In Your Marriage/Relationship, What Is:Your Level of CommitmentSelect a number from 1 to 5 where 1 is low and 5 is high.Please enter a number from 1 to 5.Your Level of DistressSelect a number from 1 to 5 where 1 is low and 5 is high.Please enter a number from 1 to 5.Your Level of Sexual SatisfactionSelect a number from 1 to 5 where 1 is low and 5 is high.Please enter a number from 1 to 5.Your Level of Emotional SatisfactionSelect a number from 1 to 5 where 1 is low and 5 is high.Please enter a number from 1 to 5.Describe your Sexual and Emotional Intimacy. What is/is not satisfying for you?What happens when you fight? What are your triggers? Can you name the cycle?How do you reconnect after an argument?Check all of the statements that reflect what you DO and the way you FEEL when you and your partner are not getting along or fighting. I attack I avoid conflict I blame I clam up I criticize I defend I get louder I get quiet I give up I give in I pursue I withdraw I seek closeness I seek distance I cling I push away I try to engage my partner I try to manage the conflict I make demands I am reasonable I take control I shut down I become passive/aggressive I stonewall What I Feel: abandoned afraid/anxious alone angry attacked blamed controlled confused criticized disconnected flooded with emotion guarded hopeless hurt like I don't know what I've done that I don't matter ignored inadequate intimidated isolated like it's always my fault judged misunderstood numb overwhelmed put down'rejected scared shut out/pushed away unable to calm myself down unable to focus my thoughts unappreciated unattractive unimportant un-loveable other What I Tend To Do:Fight/Get AssertiveFlee/Get AwaySubmit/Give InWhat My Partner Tends to Do:Fight/Get AssertiveFlee/Get AwaySubmit/Give InPrevious Therapy/CoachingNames, dates, type of therapy/coaching. Was it positive/negative/neutral?Is there anything else that you want me to know?CommentsThis field is for validation purposes and should be left unchanged.