Couples Questionnaire | The Center for Compassionate Relationships

It is easy to get started with couples therapy.
Please fill out the information in this form, all of which will be confidential. We will get back in touch with you as soon as possible.

If you're having trouble filling out the form, please download this PDF, fill out and send it to Ani. Thank you.

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Today's Date:*

Address:*

Phone:*

Name:*

Email:*

Age:*

How long have you been together?*

Are you married?*

Yes
No
Separated
Other

Previous Marriages/Committed Relationships?*

Children:*

Employment:*

Health Issues?*

Medications?*

Alcohol/Substance/Pot Usage? If so, have you received treatment?*

What do you do regularly to reduce stress?*

Trauma History?*

Current/previous individual psychotherapy?*

Current/previous couples' psychotherapy?*

Your Family of Origin

Parents:*

Siblings:*

Where did you grow up?*

Are you close to your family?*

What did you learn about relationships growing up?*

What did you learn about dealing with conflict growing up?*

What has been most satisfying about your relationship?*

What do you want to focus on and accomplish in our work together?*