Alan Behrman & Associates, PC

    2876 Johnson Ferry Rd., Suite 150 Marietta, GA 30062
    1041 Cambridge Square, Suite A Alpharetta, GA 30009
    www.alanbehrman.com 770-361-7864 info@alanbehrman.com


     

     

     
    Relationship Status:
     
     
    As you think about the primary reason that brings you here, how would you rate its frequency and your overall level of concern at this point in time?

     
    Concern:

    Frequency:

     
     
     
     
    Please rate your current level of relationship happiness by circling the number that corresponds with your current feelings about the relationship.
     

     
     
    Have you received prior couples counseling related to any of the above problems?

     
     
     
    What was the outcome (check one)?
     
    Have either you or your partner been in individual counseling before? 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?
     
    Have either you or your partner struck, physically restrained, used violence against or injured the other person?
     
     
    Has either of you threatened to separate or divorce (if married) as a result of the current relationship problems?
    If yes, who?

     
    If married, have either you or your partner consulted with a lawyer about divorce?
    If yes, who?

     
    Do you perceive that either you or your partner has withdrawn from the relationship?
    If yes, which of you has withdrawn?

     
    How frequently have you had sexual relations during the last month?
     
    How enjoyable is your sexual relationship? (Circle one)

     
    How satisfied are you with the frequency of your sexual relations? (Circle one)

     
    What is your current level of stress (overall)? (Circle one)

     
    What is your current level of stress (in the relationship)? (Circle one)