COUPLES COUNSELING INTAKE FORM Today's Date MM DD YYYY Name * First Name Last Name Age Name of Spouse First Name Last Name Age of Spouse Email * Primary Mobile Phone * (###) ### #### Are you and your spouse Believers (Christians)? * Yes we both are Neither of us are One of us Relationship Status Married living together Separated How long have you been married? * # of children: Have you received prior couples counseling? Yes No If yes, when? As you think about the primary reason that brings you here, how would you rate your overall level of concern at this point in time? Little concern Moderate concern Very serious concern Have either of you been in individual counseling? * Yes, I have Yes, my spouse has Neither of us has What do you hope to accomplish through counseling? What, if any are your concerns about coming to counseling? * Is there any other information we should know to help us better serve you and your spouse? How did you hear about us? Thank you!
