Couples Intensive — Intake Questionnaire

Basic Information

Please fill out the following questions prior to our intensive. This will save you and I time in our session. Please know that you may leave any questions blank that you are uncertain about or prefer to not answer at this time. We may review portions of this form in session together. If you have any questions please feel free to let me know in advance.

Basic Information

How long have you been together?

Do you live together?

Number of Children

Age of children

Section 2: Health & Mental Health Background

Do you have any current or past medical or health conditions?

Have you ever been diagnosed with a mental health condition? Please specify

Are you currently receiving treatment (therapy, medication, or other supports)?

Have you had COUPLES therapy before?

YES NO

Have you or your partner had INDIVIDUAL therapy before?

YES NO

Past therapy experience (individual or couples):

In the last year, have you experienced any significant life changes or stressors?

Please indicate alcohol and substance use below. How much and how often. Do you have any concerns about yours or your partner's substance/alcohol use?

Thinking about your history, are there any significant traumatic events you think I should be aware of in order to support you throughout the intensive?

Are there any current safety concerns in your relationship (emotional or physical)? (If yes, please describe)

Occupational Information

Employment

Full-time Part-time Student No

Religious/Spiritual Information

Do you consider yourself to be religious/spiritual?

Yes No

If Yes, what is your faith?

Relationship Overview

Current level of relationship happiness

1 (extremely unhappy) · 2 · 3 · 4 · 5 · 6 · 7 · 8 · 9 · 10 (extremely happy)Not answered

In your own words, describe the main challenges in your relationship right now:

If your partner were filling this out, how do you think they would describe the problem?

When did these challenges begin or become more noticeable?

What tends to happen when you and your partner have a disagreement? (Describe the pattern or cycle as best you can.)

What feels most painful or difficult for you in the relationship right now?

What is still working well in your relationship? (Strengths)

Goals for the Intensive

What do you hope to accomplish through the intensive?

Why seek support now?

Are there specific topics or issues you want to make sure we address? (e.g., communication, intimacy, parenting, trust, conflict, in-laws, etc.)

Is there something YOU could personally do to improve the relationship regardless of what partner does?

Has either of you threatened to separate/divorce as a result of current relationship problems.

YES NO

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

Sexual Relationship

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

Describe your physical intimacy. How do you feel close?

Who initiates physical or sexual intimacy? And how is it received?

How enjoyable is your sexual relationship?

1 (extremely unsatisfying) · 2 · 3 · 4 · 5 · 6 · 7 · 8 · 9 · 10 (extremely satisfying)Not answered

Emotional and Relationship History

Describe your relationship with your parents or caregivers growing up:

How were emotions handled in your home growing up? (e.g., openly expressed, avoided, minimized, explosive, etc.)

What did you learn about conflict in your family? And how do you think your upbringing shows up in your relationship today?

Who do you consider part of your support system? (e.g., friends, family, community, therapist)

How supported do you feel right now?

1 (extremely unsupported) · 2 · 3 · 4 · 5 · 6 · 7 · 8 · 9 · 10 (extremely supported)Not answered

Final Reflections

What do you wish your partner understood about you that they may not fully see right now?

Is there anything you feel nervous or hesitant about going into this intensive?

Is there anything else you would like me to know before we begin?

Please complete the following questionnaires that ask about specific symptoms. There is no right or wrong answer so try to answer them as honestly as possible.

Over the last 2 weeks, how often have you been bothered by the following problems?

1. Little interest or pleasure in doing things.

2. Feeling down, depressed or hopeless

3. Trouble falling or staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down

7. Trouble concentrating on things, such as reading the newspaper or watching television.

8. Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.

9. Thoughts that you would be better off dead or of hurting yourself in some way.

PHQ-9 (depression) — total (auto)

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SCORE INTERPRETATION: 0-4: Normal range or full remission. 5-9: Minimal depressive symptoms. 10-14: Major depression, mild severity. 15-19: Major depression, moderate severity. 20 or higher: Major depression, severe severity.

Ifyou checked of any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

If you are having thoughts of hurting yourself and have the intention of hurting yourself, you should go to your nearest hospital emergency or call 911. This survey will not be reviewed until the day of your appointment.

Over the last 2 weeks, how often have you been bothered by the following problems?

Feeling nervous, anxious, or on edge

Not being able to stop or control worrying

Worrying too much about different things

Trouble relaxing

Being so restless that it's hard to sit still

Becoming easily annoyed or irritable

Feeling afraid as if something awefull might happen

How difficult have these made it for you to do your work, take care of things at home, or get along with other people?

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Scores ≥10: Further assessment (including diagnostic interview and mental status examination) and/or referral to a mental health professional recommended. Score Symptom Severity Comments 5-9 Mild Monitor 10*-14 Moderate Possible clinically significant condition >15 Severe Active treatment probably warranted

GAD-7 (anxiety) — total (auto)

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Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then circle one of the numbers to indicate how much you have been bothered by that problem in the past month.

1. Repeated, disturbing, and unwanted memories of the stressful experience?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

2. Repeated, disturbing dreams of the stressful experience?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

4. Feeling very upset when something reminded you of the stressful experience?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)??

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

6. Avoiding memories, thoughts, or feelings related to the stressful experience?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

8. Trouble remembering important parts of the stressful experience?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

10. Blaming yourself or someone else for the stressful experience or what happened after it?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

12. Loss of interest in activities that you used to enjoy?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

13. Feeling distant or cut off from other people?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

15. Irritable behavior, angry outbursts, or acting aggressively?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

16. Taking too many risks or doing things that could cause you harm?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

17. Being "superalert" or watchful or on guard?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

18. Feeling jumpy or easily startled?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

19. Having difficulty concentrating?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

20. Trouble falling or staying asleep?

0 Not at all · 1 A little bit · 2 Moderately · 3 Quite a bit · 4 ExtremelyNot answered

adapted from: PCL-5 (8/14/2013) Weathers, Litz, Keane, Palmieri, Marx, & Schnurr -- National Center for PTSD

PCL-5 (PTSD) — total (auto)

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The following statements concern how you generally feel in close relationships (e.g., with romantic partners, close friends, or family members). Respond to each statement by indicating how much you agree or disagree with it.

1. I prefer not to show others how I feel deep down.