Below is a form that I have developed that is easy to complete and will draw a fairly complete picture of how couples are doing. You can feel free to print this out in advance and complete it before you come for counseling if you like, but are welcome to complete it when you are here.
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I have also included it so that folks on their own can focus on what the issues are in their relationship. For more evaluations about how your relationship is doing you can got to my “Strength of Relationship” form.
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Note: The rating is 1 – 5 which ranges from very little to a great deal , “1” means very little , “5” means a great deal. The one exception to this is the last question how satisfied are you with your relationship, the higher the number the more satisfaction you have. Don’t worry if this is confusing, I will be glad to explain it to you when we see each other. – Dr. Marty
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Relationship Intake Form
Welcome to my office. I realize that’s it difficult to come for marriage counseling. I have written this for the purpose of making it a little easier and to help us to quickly focus on your issues. Feel free to fill in details and circle the number of level of concern you have for that issue(s) that apply to your situation.
Name ___________________________ Date __________________
What do you and your partner have disagreements about?
very little a great deal
Money ________________________________ 1 2 3 4 5
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Parents ________________________________ 1 2 3 4 5
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In-laws _______________________________ 1 2 3 4 5
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Faithfulness ______________________________ 1 2 3 4 5
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Myself ____
My Partner ____
Sexual intimacy ___________________________1 2 3 4 5
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Addiction which one(s)_ ____________________1 2 3 4 5
Myself ____
My Partner ____
Child rearing _____________________________1 2 3 4 5
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Violence ________________________________ 1 2 3 4 5
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Myself ____
My Partner ____
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very little a great deal
Anger issues __________________ 1 2 3 4 5
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Myself ____
My Partner ____
Time spent together ____________1 2 3 4 5
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Dependability __________________________1 2 3 4 5
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My level of satisfaction with my relationship is_____
(not satisfied) 1 2 3 4 5 (very satisfied)
Other issues ___________________________________________________
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Where would you like us to start today?
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