Couples Information Form

1) Name: 4) Address: City:

2) Age:

3) Date: State: Zip:

5) Briefly, what is your main purpose in coming to couples counseling?

Instructions: To assist us in helping you, please fill out this form as fully and openly as possible. Your answers will help plan a course of couples therapy that is most suitable for you and your partner. Do not exchange this information with your partner at this time. Several of your answers on this form may be shared later with your partner during joint therapy sessions if you give us permission to share this information. For this reason you are advised to respond honestly and carefully to each item. If certain questions do not apply to you or you do not want to share this information, please leave them blank. 6) Have you been married before? Yes No If Yes, how many previous marriages have you had? 7) How long have you and your partner been in this relationship? 8) Are you and your partner presently living together? 9) Are you and your partner engaged to be married? Yes Yes When? No No 1 2 3 4 5+

10) Fill out the following information for each child of whom the natural parent is both you and your partner, children from previous relationships, and adopted children. Neither of us has children (go to next page) *Whose child? answering options: B BA M MA P PA = = = = = = One or each of us has children (continue) Both of ours, natural child Both of ours, adopted (or taken on) My natural child My child, adopted (or taken on) Partners natural child Partners child, adopted (or taken on) Age Sex F M F M F M F M F M *Whose child? Lives with whom? Yes No Yes No Yes No Yes No Yes No

Childs name 1) 2) 3) 4) 5) 11) List five qualities that initially attracted you to your partner: 1) 2) 3) 4)

Does your partner still possess this trait? Yes No Yes No Yes No Yes No

5) 12) List four negative concerns that you initially had in the relationship: 1) 2) 3) 4) 13) List five present positive attributes of your partner: 1) 2) 3) 4) 5) 14) List five present negative attributes of your partner: 1) 2) 3) 4) 5) 15) List five things you do (or could do) to make the marriage more fulfilling for your partner: 1) 2) 3) 4) 5) 16) List five things that your partner does (or could do) to make the marriage more fulfilling for you: 1) 2) 3) 4) 5)

Yes

No

Does your partner still possess this trait? Yes No Yes No Yes No Yes No Do you often praise your partner for this trait? Yes No Yes No Yes No Yes No Yes No Do you nag your partner about this trait? Yes No Yes No Yes No Yes No Yes No Do you often implement this behavior? Yes No Yes No Yes No Yes No Yes No Does your partner often implement this behavior? Yes No Yes No Yes No Yes No Yes No

17) List five expectations or dreams you had about Has this been relationships before you met your partner: fulfilled? Yes No 1) Yes No 2) 3) Yes No Yes No 4) Yes No 5) 18) On a scale of 1 to 5 rate the following items as they pertain to: 1) The present state of the relationship 2) Your need or desire for it 3) Your partners need or desire for it Circle the Appropriate Response for Each (If not applicable, leave blank.) Present state of Your need Partners need the relationship or desire or desire Poor Great Low High Low High 1) Affection 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 2) Childrearing rules 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 3) Commitment together 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 4) Communication 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 5) Emotional closeness 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 6) Financial security 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 7) Honesty 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 8) Housework sharing 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 9) Love 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 10) Physical attraction 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 11) Religious commitment 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 12) Respect 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 13) Sexual fulfillment 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 14) Social life together 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 15) Time together 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 16) Trust 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Other (specify) 17) 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 18) 19) 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 20) 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 19) For couples living together. Which partner spends more time conducting the following activities? Circle the Appropriate Response for Each (If not applicable, leave blank.) (M = Me P = Partner E = Equal time) Is this equitable (fair)? Comments 1) Auto repairs M P E Yes No 2) Child care M P E Yes No 3) Child discipline M P E Yes No Yes No 4) Cleaning bathrooms M P E 5) Cooking M P E Yes No Yes No 6) Employment M P E 7) Grocery shopping M P E Yes No

8) House cleaning 9) Inside repairs 10) Laundry 11) Making bed 12) Outside repairs 13) Recreational events 14) Social activities 15) Sweeping kitchen 16) Taking out garbage 17) Washing dishes 18) Yard work 19) Other: 20) Other:

M M M M M M M M M M M M M

P P P P P P P P P P P P S

E E E E E E E E E E E E E

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No No

20) If some of the following behaviors take place only during MILD arguments circle an M in the appropriate blanks. If they take place only during SEVERE arguments, circle an S. If they take place during ALL arguments circle an A. Fill this out for you and your impression of your partner. If certain behaviors do not take place, leave them blank. Circle the Appropriate Response for Each (M = Mild arguments only S = Severe arguments only A = All arguments) Behavior By me By partner Should this change? 1) Apologize M S A M S A Yes No 2) Become silent M S A M S A Yes No 3) Bring up the past M S A M S A Yes No 4) Criticize M S A M S A Yes No 5) Cruel accusations M S A M S A Yes No 6) Cry M S A M S A Yes No 7) Destroy property M S A M S A Yes No 8) Leave the house M S A M S A Yes No 9) Make peace M S A M S A Yes No 10) Moodiness M S A M S A Yes No 11) Not listen M S A M S A Yes No 12) Physical abuse M S A M S A Yes No Yes No 13) Physical threats M S A M S A 14) Sarcasm M S A M S A Yes No 15) Scream M S A M S A Yes No Yes No 16) Slam doors M S A M S A 17) Speak irrationally M S A M S A Yes No 18) Speak rationally M S A M S A Yes No Yes No 19) Sulk M S A M S A 20) Swear M S A M S A Yes No 21) Threaten breaking up M S A M S A Yes No 22) Threaten to take kids M S A M S A Yes No Yes No 23) Throw things M S A M S A 24) Verbal abuse M S A M S A Yes No 25) Yell M S A M S A Yes No 26) M S A M S A Yes No M S A M S A Yes No 27) 28) M S A M S A Yes No

21) How often do you have:

Mild arguments? Severe arguments?

22) When a MILD argument is over 23) When a SEVERE argument is over how do you usually feel? how do you usually feel? Check Appropriate Responses Check Appropriate Responses Angry Lonely Angry Lonely Anxious Nauseous Anxious Nauseous Childish Numb Childish Numb Defeated Regretful Defeated Regretful Depressed Relieved Depressed Relieved Guilty Stupid Guilty Stupid Happy Victimized Happy Victimized Hopeless Worthless Hopeless Worthless Irritable Irritable 24) Which of the following issues or behaviors of you and/or your partner may be attributable to your relationship or personal conflicts? If an item does not apply, leave it blank. Circle the Appropriate Responses (M = My behavior P = Partners behavior B = Both) Alcohol consumption M P B Perfectionist M P B Childishness M P B Possessive M P B Controlling M P B Spends too much M P B Defensiveness M P B Steals M P B Degrading M P B Stubbornness M P B Demanding M P B Uncaring M P B Drugs M P B Unstable M P B Flirts with others M P B Violent M P B Gambling M P B Withdrawn M P B Irresponsibility M P B Works too much M P B Lies M P B Other (specify) Past marriage(s)/relationship(s) M P B M P B Others advice M P B M P B M P B Outside interests M P B Past failures M P B M P B

25) In the remaining space please provide additional information that would be helpful:

, hereby give my permission for this clinic to share the I, information that I provide on this form to (partner) when it is deemed appropriate by an agreement between me, my partner, and our therapist. This sharing of information may take place only during a joint counseling session (both partners present). Clients signature: Date: / /

PLEASE RETURN THIS AND OTHER ASSESSMENT MATERIALS DURING YOUR NEXT APPOINTMENT