Relationship Status:

MarriedSeparatedDivorcedDating

CohabitatingLiving togetherLiving apart

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:

No concernLittle concernModerate concernSerious concernVery serious concern

Frequency:

No occurrenceOccurs rarelyOccurs sometimesOccurs frequentlyOccurs nearly always

1 (extremely unhappy)2345678910 (extremely happy)

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.

YesNo

Do either you or your partner drink alcohol to intoxication or take drugs to intoxication?

YesNo

Have either you or your partner struck, physically restrained, used violence against or injured the other person?

YesNo

Has either of you threatened to separate or divorce (if married) as a result of the current relationship problems?

YesNo

If yes, who?

MePartnerBoth of us

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

YesNo

If yes, who?

MePartnerBoth of us

Do you perceive that either you or your partner has withdrawn from the relationship?

YesNo

If yes, which of you has withdrawn?

MePartnerBoth of us

How frequently have you had sexual relations during the last month?

How enjoyable is your sexual relationship? (Circle one)

1(extremely unpleasant)2345678910(extremely pleasant)

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

1(extremely unsatisfied)2345678910(extremely satisfied)

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

1(no stress)2345678910(high stress)

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

1(no stress)2345678910(high stress)