(NG) Relationship Counselling Initial Consultation Intake Form

To get the most out of each counselling session, please take a moment to consider the following questions prior to our session. It will help guide our session for maximum impact.

Please take a moment to consider how you want to use your time with me. I invite you to be open and honest in your answers.

Your Name

First Name

Last Name

Partners Name

First Name

Last Name

How old are you? How old is your Partner?

What is your occupation? What is your partners occupation?

How long have you been a couple for?

Do you have children? How many, how old and what are their names?

Have you or your partner been diagnosed with a mental health disorder? Do you have a treatment plan?

Why are you seeking relationship counselling?

What is your biggest challenge when dealing with this?

What areas of your life have been affected by this challenge? (Family, Work, Social)

Has there previously been any infidelity within your relationship? Please give details

Have you had any support for your relationship in the past? Please give details

What are some of your fondest memories in your relationship?

Is there anything else you would like me to know before we embark on our counselling journey together?