Please rate your current level of relationship happiness by circling the number that corresponds with your current feelings about the relationship. 1 2 3 4 5 6 7 8 9 10 (extremely unhappy) (extremely happy) Please make at one suggestion as to something you could personally do to improve the relationship regardless of what your partner does. Have you received prior couples counseling related to any of the above problems? Yes No □ □ If yes, when: Where: By whom: Length of treatment: Problems treated: What was the outcome (check one)? Very successful Somewhat successful Stayed the same Somewhat worse Much worse □ □ □ □ Have either you or your partner been in counseling before? Yes No individual □ □ If so, give a brief summary of concerns that you addressed. Do either you or your partner drink alcohol to intoxication or take drugs to intoxication? If yes for either, who, how often and what drugs or alcohol?
Please rate your current level of relationship happiness by circling the number that corresponds with your current feelings about the relationship. 1 2 3 4 5 6 7 8 9 10 (extremely unhappy) (extremely happy) Please make at one suggestion as to something you could personally do to improve the relationship regardless of what your partner does. Have you received prior couples counseling related to any of the above problems? □ Yes □ No If yes, when: By whom: Where: Length of treatment: Problems treated: What was the outcome (check one)? Very successful □ Somewhat successful □ Stayed the same □ Somewhat worse □ Much worse Have either you or your partner been in individual counseling before? □ Yes □ No If so, give a brief summary of concerns that you addressed. Do either you or your partner drink alcohol to intoxication or take drugs to intoxication? If yes for either, who, how often and what drugs or alcohol?
couplesintake.docx