Couples Therapy Intake Form Home » Couples Therapy Intake Form (Confidential – For Clinical Use Only) Couples Therapy Intake Form "*" indicates required fields LinkedInThis field is for validation purposes and should be left unchanged.General Information Insured Full Name*Date Of Birth MM slash DD slash YYYY AgeAddress Street Address City State ZIP Code Phone*Email* OccupationEmergency Contact (name/relationship)Emergency Contact Phone NumberSpouseFull NameDate Of Birth MM slash DD slash YYYY AgeAddress(if different): Street Address City State ZIP Code PhoneEmail OccupationEmergency Contact (name/relationship)Emergency Contact Phone NumberRelationship InformationRelationship Status (check one) Living Together Married Separated Divorced Other Other*Length of RelationshipLength of Marriage (if applicable)Children (names/ages, if any)Referral How Did You Hear About This Practice?What Brings You to Couples Therapy at This Time?What Brings You to Couples Therapy at This Time?Have Either of You Had Couples Therapy Before? Yes No If Yes, When and What Was the Outcome?Presenting Concerns Communication difficulties Trust Issues / Infidelity Frequent Conflict / Anger Parenting Differences Sexual Intimacy Concerns Financial Stress Substance Abuse Extended Family Concerns Life Transitions (e.g., moving, career change) Considering Separation/Divorce Other Other*Individual History InsuredCurrent Physical Health Excellent Good Fair Poor Current Mental Health ConcernsPast Mental Health Treatment (Therapy, Medications, Hospitalizations)Substance Use (Alcohol, Drugs, Nicotine, Other)SpouseCurrent Physical Health Excellent Good Fair Poor Current Mental Health ConcernsPast Mental Health Treatment (Therapy, Medications, Hospitalizations)Substance Use (Alcohol, Drugs, Nicotine, Other)Relationship Strengths & GoalsWhat Do You Value Most About Your Partner/relationship?What Are Your Goals for Couples Therapy?Risk & SafetyDo Arguments Ever Escalate to Physical Aggression? Yes No Do You Feel Emotionally or Physically Unsafe in This Relationship? Yes No Do You Have Concerns About Self-harm or Harming Others? Yes No If Yes, Please ExplainConsent to Treatment Consent to Treatment* I/we understand that:*- Couples therapy is a collaborative process and outcomes cannot be guaranteed. - Sessions may involve discussing sensitive topics. - Information disclosed in sessions is confidential, with exceptions as required by law (e.g., risk of harm, abuse reporting). Missed sessions and sessions canceled less than 24 hrs. prior to session will be charged. We authorize Dr Michael Fish to provide marital treatment and to bill our insurance company with information we provide (if not self-pay) Insured Signature*Date* MM slash DD slash YYYY Spouse Signature*Date* MM slash DD slash YYYY
