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Couple First Session Form
Therapist First Session Form
Appointment Id:
Session Date
Session Time
Status of Session
Full show
Partial show
Cancelled
Rescheduled
No Show
Did the session start and end on time ?
Yes to Both
No to Both
Started on time, extended time
Started late, ended on time
Client 1
Name:
How did the client attend the session??
In Person
Video on Gmeet
Audio on Gmeet
Video on WhatsApp
Audio on WhatsApp
Phone call
Others
Please mention the medium of the session
Has the client been diagnosed with any mental or physical health concerns?
Mental Health
Physical Health
None
Mental Health Concerns
Mood disorders
Anxiety disorders
Eating disorders
Personality disorders
Substance dependancy
Neurological disorders
Others
Physical Health Concerns
Has the client1 taken love language quiz?
Yes
No
Not required
What are their top 2 love languages?
Quality Time
Words of affirmation
Physical Touch
Acts of Service
Has the client taken fight language quiz?
Yes
No
Not required
What are their top 2 fight languages?
Justification: You had it coming
Distraction: Look over there
Retribution: You'll pay for that
Indignation: How could you?
Are they parents?
Yes
No
In the past
Do they have any concerns?
Yes
No
Not explored
Do they have any concerns?
Yes
No
What are the parenting concerns?
Loss of a child
Parenting style not matching
Role not divided appropriately
Family planning
Parenting style
Empty nest
Others
What are the concerns?
Desire for child/children
Don't want a child/children
Want to look for alternative ways
Unable to concieve
Partner doesn't want
Others
What are their primary concerns?
Pre-marital
Emotional
Abuse
Sexual
Spiritual
Financial
Parenting
Lifestyle
Family/ Support system
Pre-marital
Culture clash
Religion clash
Family clash
Life goals not aligning
Fear of commitment
Role confusion
General bonding concerns
Anxiety
Others
Emotional-Concerns
Neglect
Unvailable emotionally
Disrespect
Emotional-mental abuse
Missing spark
Trust issues
Level of commitment
Love language not matching
Communication
Argument
Feels like the giver
Feels like the reciever/ indebted
Dependency
Infidelity
Others
Abuse
Sexual
Physical
Others
Sexual Concerns
Unsatisfied
Discomfort
Disinterest
Biological
Physical concerns
Sexual pain
Arousal
Others
Spiritual concerns
Life goals not aligning
Ideologies not aligning
Religious beliefs not aligning
Purpose of relationship feels lost
Others
Financial Concerns
Inequality
Abuse
Incapacity to earn
Dependency
No control
Deception
Dowry
Others
Lifestyle Concerns
Habits
Work stress
Lack of time
Routine issues
Others
Family Support
In-laws Issues
Community acceptance
Children not supporting
Empty nest
Others
Is the client at risk of suicide
Yes
No
Maybe
Don't know
Is there a barriers to therapy?
Yes
No
The partner has barriers
What are the barriers to therapy?
Financial constrains
Timings
Lack of knowledge/ understanding
Lack of enthusiam to work on the relationship
Unrealistic expectations
Partner is resistant so they are resistant
Resistance to change
Therapeutic alliance
Therapy not needed
Others
What was the focus of the session?
Solution
Awareness
Venting
Others
What stage is the client at?
Maintainance
Resolution
Exploration
Identification
Orientation
Was homework given?
Yes
No
What kind of selfwork was given?
Physical
Thought
Written
Communiation
Others
Client 2
Name:
How did the client attend the session??
In Person
Video on Gmeet
Audio on Gmeet
Video on WhatsApp
Audio on WhatsApp
Phone call
Others
Please mention the medium of the session
Has the client been diagnosed with any mental or physical health concerns?
Mental Health
Physical Health
None
Mental Health Concerns
Mood disorders
Anxiety disorders
Eating disorders
Personality disorders
Substance dependancy
Neurological disorders
Others
Physical Health Concerns
Has the client1 taken love language quiz?
Yes
No
Not required
What are their top 2 love languages?
Quality Time
Words of affirmation
Physical Touch
Acts of Service
Has the client taken fight language quiz?
Yes
No
Not required
What are their top 2 fight languages?
Justification: You had it coming
Distraction: Look over there
Retribution: You'll pay for that
Indignation: How could you?
Are they parents?
Yes
No
In the past
Do they have any concerns?
Yes
No
Not explored
Do they have any concerns?
Yes
No
What are the parenting concerns?
Loss of a child
Parenting style not matching
Role not divided appropriately
Family planning
Parenting style
Empty nest
Others
What are the concerns?
Desire for child/children
Don't want a child/children
Want to look for alternative ways
Unable to concieve
Partner doesn't want
Others
What are their primary concerns?
Pre-marital
Emotional
Abuse
Sexual
Spiritual
Financial
Parenting
Lifestyle
Family/ Support system
Pre-marital
Culture clash
Religion clash
Family clash
Life goals not aligning
Fear of commitment
Role confusion
General bonding concerns
Anxiety
Others
Emotional-Concerns
Neglect
Unvailable emotionally
Disrespect
Emotional-mental abuse
Missing spark
Trust issues
Level of commitment
Love language not matching
Communication
Argument
Feels like the giver
Feels like the reciever/ indebted
Dependency
Infidelity
Others
Abuse
Sexual
Physical
Others
Sexual Concerns
Unsatisfied
Discomfort
Disinterest
Biological
Physical concerns
Sexual pain
Arousal
Others
Spiritual concerns
Life goals not aligning
Ideologies not aligning
Religious beliefs not aligning
Purpose of relationship feels lost
Others
Financial Concerns
Inequality
Abuse
Incapacity to earn
Dependency
No control
Deception
Dowry
Others
Lifestyle Concerns
Habits
Work stress
Lack of time
Routine issues
Others
Family Support
In-laws Issues
Community acceptance
Children not supporting
Empty nest
Others
Is the client at risk of suicide
Yes
No
Maybe
Don't know
Is there a barriers to therapy?
Yes
No
The partner has barriers
What are the barriers to therapy?
Financial constrains
Timings
Lack of knowledge/ understanding
Lack of enthusiam to work on the relationship
Unrealistic expectations
Partner is resistant so they are resistant
Resistance to change
Therapeutic alliance
Therapy not needed
Others
What was the focus of the session?
Solution
Awareness
Venting
Others
What stage is the client at?
Maintainance
Resolution
Exploration
Identification
Orientation
Was homework given?
Yes
No
What kind of selfwork was given?
Physical
Thought
Written
Communiation
Others
What activity/ homework goes in Care-plan
Therapist
Did you expereicence transference during the session?
Yes
No
Did you expereicence counter transference during the session?
Yes
No
Do you need supervision for this case?
Yes
No
Was this the termination session?
Yes
No
What are your plans for therapy ahead?
Would you recommend therapy packages to them?
Yes
No
Which one would you recommend?
1 session
3 sessions
5 sessions
When would you like reminder to check-in on this client?
What primary feelings are you left with?
Happy
Angry
Fearful
Sad
Surprise
Peaceful
What is your energy levels after the session?
Exhuasted
Tired
Alright
Good
Enthusiastic
Did the session start and end on time ?
Yes to Both
No to Both
Started on time, extended time
Started late, ended on time
Client 1
Name:
How did the client attend the session??
In Person
Video on Gmeet
Audio on Gmeet
Video on WhatsApp
Audio on WhatsApp
Phone call
Others
Please mention the medium of the session
Has the client been diagnosed with any mental or physical health concerns?
Mental Health
Physical Health
None
Mental Health Concerns
Mood disorders
Anxiety disorders
Eating disorders
Personality disorders
Substance dependancy
Neurological disorders
Others
Physical Health Concerns
Has the client1 taken love language quiz?
Yes
No
Not required
What are their top 2 love languages?
Quality Time
Words of affirmation
Physical Touch
Acts of Service
Has the client taken fight language quiz?
Yes
No
Not required
What are their top 2 fight languages?
Justification: You had it coming
Distraction: Look over there
Retribution: You'll pay for that
Indignation: How could you?
Are they parents?
Yes
No
In the past
Do they have any concerns?
Yes
No
Not explored
Do they have any concerns?
Yes
No
What are the parenting concerns?
Loss of a child
Parenting style not matching
Role not divided appropriately
Family planning
Parenting style
Empty nest
Others
What are the concerns?
Desire for child/children
Don't want a child/children
Want to look for alternative ways
Unable to concieve
Partner doesn't want
Others
What are their primary concerns?
Pre-marital
Emotional
Abuse
Sexual
Spiritual
Financial
Parenting
Lifestyle
Family/ Support system
Pre-marital
Culture clash
Religion clash
Family clash
Life goals not aligning
Fear of commitment
Role confusion
General bonding concerns
Anxiety
Others
Emotional-Concerns
Neglect
Unvailable emotionally
Disrespect
Emotional-mental abuse
Missing spark
Trust issues
Level of commitment
Love language not matching
Communication
Argument
Feels like the giver
Feels like the reciever/ indebted
Dependency
Infidelity
Others
Abuse
Sexual
Physical
Others
Sexual Concerns
Unsatisfied
Discomfort
Disinterest
Biological
Physical concerns
Sexual pain
Arousal
Others
Spiritual concerns
Life goals not aligning
Ideologies not aligning
Religious beliefs not aligning
Purpose of relationship feels lost
Others
Financial Concerns
Inequality
Abuse
Incapacity to earn
Dependency
No control
Deception
Dowry
Others
Lifestyle Concerns
Habits
Work stress
Lack of time
Routine issues
Others
Family Support
In-laws Issues
Community acceptance
Children not supporting
Empty nest
Others
Is the client at risk of suicide
Yes
No
Maybe
Don't know
Is there a barriers to therapy?
Yes
No
The partner has barriers
What are the barriers to therapy?
Financial constrains
Timings
Lack of knowledge/ understanding
Lack of enthusiam to work on the relationship
Unrealistic expectations
Partner is resistant so they are resistant
Resistance to change
Therapeutic alliance
Therapy not needed
Others
What was the focus of the session?
Solution
Awareness
Venting
Others
What stage is the client at?
Maintainance
Resolution
Exploration
Identification
Orientation
Was homework given?
Yes
No
What kind of selfwork was given?
Physical
Thought
Written
Communiation
Others
Client 2
Name:
How did the client attend the session??
In Person
Video on Gmeet
Audio on Gmeet
Video on WhatsApp
Audio on WhatsApp
Phone call
Others
Please mention the medium of the session
Has the client been diagnosed with any mental or physical health concerns?
Mental Health
Physical Health
None
Mental Health Concerns
Mood disorders
Anxiety disorders
Eating disorders
Personality disorders
Substance dependancy
Neurological disorders
Others
Physical Health Concerns
Has the client1 taken love language quiz?
Yes
No
Not required
What are their top 2 love languages?
Quality Time
Words of affirmation
Physical Touch
Acts of Service
Has the client taken fight language quiz?
Yes
No
Not required
What are their top 2 fight languages?
Justification: You had it coming
Distraction: Look over there
Retribution: You'll pay for that
Indignation: How could you?
Are they parents?
Yes
No
In the past
Do they have any concerns?
Yes
No
Not explored
Do they have any concerns?
Yes
No
What are the parenting concerns?
Loss of a child
Parenting style not matching
Role not divided appropriately
Family planning
Parenting style
Empty nest
Others
What are the concerns?
Desire for child/children
Don't want a child/children
Want to look for alternative ways
Unable to concieve
Partner doesn't want
Others
What are their primary concerns?
Pre-marital
Emotional
Abuse
Sexual
Spiritual
Financial
Parenting
Lifestyle
Family/ Support system
Pre-marital
Culture clash
Religion clash
Family clash
Life goals not aligning
Fear of commitment
Role confusion
General bonding concerns
Anxiety
Others
Emotional-Concerns
Neglect
Unvailable emotionally
Disrespect
Emotional-mental abuse
Missing spark
Trust issues
Level of commitment
Love language not matching
Communication
Argument
Feels like the giver
Feels like the reciever/ indebted
Dependency
Infidelity
Others
Abuse
Sexual
Physical
Others
Sexual Concerns
Unsatisfied
Discomfort
Disinterest
Biological
Physical concerns
Sexual pain
Arousal
Others
Spiritual concerns
Life goals not aligning
Ideologies not aligning
Religious beliefs not aligning
Purpose of relationship feels lost
Others
Financial Concerns
Inequality
Abuse
Incapacity to earn
Dependency
No control
Deception
Dowry
Others
Lifestyle Concerns
Habits
Work stress
Lack of time
Routine issues
Others
Family Support
In-laws Issues
Community acceptance
Children not supporting
Empty nest
Others
Is the client at risk of suicide
Yes
No
Maybe
Don't know
Is there a barriers to therapy?
Yes
No
The partner has barriers
What are the barriers to therapy?
Financial constrains
Timings
Lack of knowledge/ understanding
Lack of enthusiam to work on the relationship
Unrealistic expectations
Partner is resistant so they are resistant
Resistance to change
Therapeutic alliance
Therapy not needed
Others
What was the focus of the session?
Solution
Awareness
Venting
Others
What stage is the client at?
Maintainance
Resolution
Exploration
Identification
Orientation
Was homework given?
Yes
No
What kind of selfwork was given?
Physical
Thought
Written
Communiation
Others
What activity/ homework goes in Care-plan
Therapist
Did you expereicence transference during the session?
Yes
No
Did you expereicence counter transference during the session?
Yes
No
Do you need supervision for this case?
Yes
No
Was this the termination session?
Yes
No
What are your plans for therapy ahead?
Would you recommend therapy packages to them?
Yes
No
Which one would you recommend?
1 session
3 sessions
5 sessions
When would you like reminder to check-in on this client?
What primary feelings are you left with?
Happy
Angry
Fearful
Sad
Surprise
Peaceful
What is your energy levels after the session?
Exhuasted
Tired
Alright
Good
Enthusiastic