Couples Therapy Intake Questionnaire

Serenity Psychology
Naomi Bernstein, Psy.D.
1 Sunset Avenue, Lynbrook, NY 11563 • Tel: (516) 359-5030 • Email: drnaomi@yahoo.com
1
Couples Therapy Intake Questionnaire

Please check any of the following that you have experienced in the past 6 months:

□ Headache
□ High Blood Pressure
□ Irritable Bowel
□ Chronic Pain
□ Loss of Consciousness
□ Chronic Fatigue
□ Dizziness
□ Faintness
□ Shortness of Breath
□ Increased Appetite
□ Decreased Appetite
□ Eating Problems
□ Excessive Eating
□ Trouble Concentrating
□ Sleeping Difficulties
□ Excessive Sleep
□ Lack of Need for Sleep
□ Low Motivation
□ Low Self-Esteem
Please describe:__________________________________________________________
□ Depressed Mood
Please describe:__________________________________________________________
□ Loss of Interest or Pleasure
Please describe:__________________________________________________________
□ Tearing or Crying Spells
□ Hopelessness
Please describe:__________________________________________________________
□ Anxiety
Please describe:__________________________________________________________
□ Fear
Please describe:__________________________________________________________
□ Panic
Please describe:__________________________________________________________
□ Delusions
Please describe:__________________________________________________________
□ Hallucinations
Please describe:__________________________________________________________
□ Mood Swings

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□ Excessive Energy
□ Impulsivity
□ Sensation Seeking Behavior
Please describe:__________________________________________________________
□ Irritability and/or Anger
□ Paranoia
□ Flashbacks
□ Nightmares
□ Isolation from Others
□ Withdrawal from Others
□ Thoughts of Death
Please describe:__________________________________________________________
□ Engaging in Self-Harming Behavior(s)
Please describe:__________________________________________________________
□ Other
Please describe:__________________________________________________________

Do you currently suffer from a serious health condition?
□ Yes
Please describe:__________________________________________________________
________________________________________________________________________
□ No

Do you drink alcohol?
□ Yes
Please describe type, amount, and frequency:__________________________________
________________________________________________________________________
□ No

Do you use recreational drugs?
□ Yes
Please describe type, amount, and frequency:__________________________________
________________________________________________________________________
□ No

Have you ever thought about harming yourself or attempting suicide?
□ Yes
Please describe:__________________________________________________________
_______________________________________________________________________
□ No

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Do you have thoughts or urges to harm others?
□ Yes
Please describe:__________________________________________________________
_______________________________________________________________________
□ No

Is there a history of mental illness in your family?
□ Yes
Please describe who and type:_______________________________________________
□ No

Have you seen a mental health professional before?
□ Yes
Please specify dates, reasons for counseling, and
experience:______________________________________________________________
________________________________________________________________________
________________________________________________________________________
□ No

Have you ever been hospitalized for a psychiatric issue?
□ Yes
Please describe where, when, and why:_______________________________________
________________________________________________________________________
________________________________________________________________________
□ No

Please specify all medications and supplements you are presently taking and for what reason:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

If taking prescription medication, who is your prescribing MD? Please include type of MD,
name, and phone number:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

What is your level of education? Please include highest grade/degree and type of degree:
______________________________________________________________________________
______________________________________________________________________________

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What is your current occupation? What do you do? How long have you been doing it? Do you
enjoy it?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

What coping strategies do you use during a stressful time? Please select all that apply:
□ Relaxation Techniques
□ Exercise/Recreational Activities
□ Engage in Personal Hobbies
□ Turn to Spirituality
□ Emotionally Eat
□ Vent to friends and/or family members
□ Withdraw from others
□ Avoidance
□ Use Humor
□ Other
Please describe:__________________________________________________________

What brings you to couples counseling at this time? Is there something specific, such as a
particular conflict or event? Please be as detailed as you can.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

How long have you been in a relationship with your partner and how would you describe it?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

What is your current living situation like with your partner?
______________________________________________________________________________
______________________________________________________________________________

Have you thought about separating from your partner?
□ Yes
Please describe:__________________________________________________________
□ No

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Do you have children?
□ Yes
How old are they? Are they from your current relationship?
________________________________________________________________________
________________________________________________________________________
□ No

What changes do you believe your partner needs to make in your relationship? What changes
do you believe you need to make in your relationship?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

How would you rate your happiness level in your current romantic relationship from 1-10?
______________________________________________________________________________

What are the main issues in your relationship that you need to improve on (i.e.,
communication)?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Do you know what fills your partner’s mind on a daily basis? Do you believe your partner knows
what fills your mind on a daily basis? Please describe:
______________________________________________________________________________
______________________________________________________________________________

Do you feel loved and appreciated in your relationship? Do you think your partner feels loved
and appreciated in your relationship?
______________________________________________________________________________
______________________________________________________________________________

Do you enjoy spending time with your partner? Do you think your partner enjoys spending time
with you?
______________________________________________________________________________
______________________________________________________________________________

Has there been a breach in trust in your relationship?
□ Yes
Please describe:__________________________________________________________
□ No

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What issues are currently affecting your relationship with your partner? Please select all that
apply:
□ Communication
□ Trust Issues
□ Affection
□ Sexual Intimacy
□ Lack of Emotional Support
□ Spending Quality Time Together
□ Extra-Relationship Affair
□ Self-Esteem Issues
□ Temper Outbursts
□ Loss of Independence
□ Job Issues
□ Division of Household Work
□ Blended Family Issues
□ Dealing with Extended Family
□ Finances
□ Legal Issues
□ Chronic Illness
□ Death

What are the major stresses in your life? What are the major stresses in your partner’s life?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

How do you and your partner each handle stress?
______________________________________________________________________________
______________________________________________________________________________

When you are stressed, does it negatively affect your relationship?
□ Yes
Please describe:__________________________________________________________
□ No

When your partner is stressed, does it negatively affect your relationship?
□ Yes
Please describe:__________________________________________________________
□ No

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Is sexual intimacy an issue in your relationship? Please select all issues that apply:
□ Frequency of Sex
□ Being able to candidly talk about sexual problems
□ Lack of Romance
□ Sexual Dysfunction(s)
Please describe:__________________________________________________________
□ Other
Please describe:__________________________________________________________
□ No

Has there been an important event that has occurred in your and/or your partner’s life (i.e.,
loss of job, change in role, illness, death)?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Have major issues about children arisen in your relationship?
□ Yes
Please describe:__________________________________________________________
□ No

Has there been an extra-relationship affair in your relationship?
□ Yes
Please describe:__________________________________________________________
□ No

How do you and your partner handle disagreements when they arise?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

When disagreements arise between you and your partner, which of these reactions do you
typically display? Select all that apply:
□ Physical Aggressiveness
□ Verbal Aggressiveness
□ Anger
□ Withdrawn
□ Defensive
□ Criticize Partner
□ Avoidance

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□ Shutting Down
□ Pressure to Communicate Immediately
□ Denial
□ Make Excuses/Justifications for Actions

When disagreements arise between you and your partner, which of these reactions does he or
she typically display? Select all that apply:
□ Physical Aggressiveness
□ Verbal Aggressiveness
□ Anger
□ Withdrawn
□ Defensive
□ Criticize Partner
□ Avoidance
□ Shutting Down
□ Pressure to Communicate Immediately
□ Denial
□ Make Excuses/Justifications for Actions

Has violence ever occurred in your relationship?
□ Yes
Please describe:__________________________________________________________
□ No

Has there been a problem with substance use and/or addictive behaviors (e.g., gambling,
pornography) in your relationship?
□ Yes
Please describe who, type, and
frequency:_______________________________________________________________
________________________________________________________________________
□ No

Is sharing the household workload an issue in your relationship?
□ Yes
Please describe:__________________________________________________________
________________________________________________________________________
□ No

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Is sharing common spiritual beliefs an issue in your relationship?
□ Yes
Please describe:__________________________________________________________
________________________________________________________________________
□ No
Please describe:__________________________________________________________
________________________________________________________________________

Which of the following did you experience as a child? Please select and answer to all that apply:

□ I and/or a family member was physically, emotionally, or sexually abused as a child.
Please describe:__________________________________________________________
________________________________________________________________________
________________________________________________________________________
□ My family members(s) suffered from a mental illness.
Please describe who and type:_______________________________________________
________________________________________________________________________
□ One or both of my parents/caregivers struggled with substance use.
Please describe who, type, amount, and frequency:_____________________________
________________________________________________________________________
□ I lived in a single-parent home.
Please describe:__________________________________________________________
________________________________________________________________________
□ One or both of my parents were emotionally unavailable or absent.
Please describe:__________________________________________________________
________________________________________________________________________
□ My parents did not make me feel good about myself.
□ Affection was not expressed in my family.
□ My parents were not emotionally expressive.
□ I did not spend quality time with my family as a child.
Please describe:__________________________________________________________
________________________________________________________________________
□ I was not able to depend on my parents for help.
Please describe:__________________________________________________________
________________________________________________________________________
□ My family struggled financially.
□ I did not have a supportive relationship with my siblings.
□ My home was not open socially to guests or visitors.
□ I felt criticized by my parents.
Please describe:__________________________________________________________
________________________________________________________________________

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□ My parents used inconsistent and punitive punishment towards me and/or my siblings.
Please describe:__________________________________________________________
________________________________________________________________________
________________________________________________________________________
□ I was abused and/or bullied by my peers.
Please describe:__________________________________________________________
________________________________________________________________________
□ I lived in a blended family.
Please describe:__________________________________________________________
________________________________________________________________________
□ I did not have a good relationship with my step-family member(s).
Please describe:__________________________________________________________
________________________________________________________________________
________________________________________________________________________
□ I generally feel like I had a good childhood.
Please describe:__________________________________________________________
________________________________________________________________________
________________________________________________________________________

Couples Therapy Intake Questionnaire

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