Intake form Couples therapy

What is your name?

What is your age?

Which gender do you identify with?

What is your partner’s name?

What is your partner’s age?

Which gender does your partner identify with?

What is your relationship status?

Where are you currently residing? (City)*

What is your current occupation status?

How long have you been in a relationship for?

Have you been to couples therapy before? If yes, please mention a little bit about your previous experience.

What are your current goals/expectations from couples therapy?