Couples Counselling Intake Form, One Form Per Partner

The form itself

A static copy of the finished form, exactly as it renders. Nothing here can be filled in or submitted, so read it as a reference and build your own from the button above.

One partner, one form

Two Chairs Counselling. Each of you fills this in on your own. Your counsellor reads both before the first session and neither of you sees the other's answers.

About you

Your name *

Your partner's name *

Your mobile *

Your email *

The relationship

How long have you been together, in years? *

How are you living at the moment? *

Together, in one home

Together, but sleeping separately

Living apart by choice, seeing each other

Living apart because of work or distance

Recently separated, still in the same house

Separated, living in different homes

Are there children in either household? *

No children

Children we have together, living with us

Children from earlier relationships, living with us

Both, in a blended household

Children who live somewhere else some of the time

Expecting a child now

Why you are here

What you write in this section is health information and is read only by your counsellor. It is not shown to your partner, it is not read out in the session, and the counsellor will not repeat it. It shapes how the first session is run rather than being used as evidence about anybody.

What would you like to be different in six months? *

What do you think your partner would say is the problem?

Where are you with the relationship right now? *

Committed, and wanting it to work better

Committed, but running out of patience

Unsure whether to stay

Leaning towards ending it

Already decided to end it, and want help doing that well

I would rather say this in the session

Have you had counselling before, together or separately? *

Neither of us, ever

Me, on my own

My partner, on their own

Both of us, separately

The two of us together, with somebody else

The two of us together, and it did not go well

Safety

Everybody is asked this, on both forms, every time. Couples work is not safe or appropriate where one person is afraid of the other, so the answer changes what is offered rather than being held against anyone. If you answer yes or prefer to speak privately, your counsellor will arrange an individual conversation before any joint session. If you are in immediate danger, contact your local emergency number now rather than waiting for an appointment.

Is there anything in the relationship that frightens you, or that you feel you cannot say in front of your partner? *

No

Yes

I would rather speak to the counsellor privately first

Confidentiality and consent

In couples work the client is the relationship, and this practice holds no secrets on behalf of one partner. Your counsellor will not repeat what is on this form, but will also not keep an ongoing secret for one of you during the work, and will say so openly if asked to. Anything disclosed in an individual conversation about safety is handled separately and is not shared without your agreement. The usual limits apply: serious risk to any person, including a child, or a legal requirement to disclose.

Confidentiality between partners *

I have read how confidentiality works between partners and agree to counselling on that basis

Signature *

Every field, and what it collects

The complete field list, in the order respondents meet it.

Your nameShort textRequired
Your partner's nameShort textRequired
Your mobileShort textRequired
Your emailShort textRequired
How long have you been together, in years?NumberRequired
How are you living at the moment?Single choiceRequired: Options: Together, in one home · Together, but sleeping separately · Living apart by choice, seeing each other · Living apart because of work or distance · Recently separated, still in the same house · Separated, living in different homes
Are there children in either household?Single choiceRequired: Options: No children · Children we have together, living with us · Children from earlier relationships, living with us · Both, in a blended household · Children who live somewhere else some of the time · Expecting a child now
What would you like to be different in six months?Long textRequired
What do you think your partner would say is the problem?Long text
Where are you with the relationship right now?Single choiceRequired: Options: Committed, and wanting it to work better · Committed, but running out of patience · Unsure whether to stay · Leaning towards ending it · Already decided to end it, and want help doing that well · I would rather say this in the session
Have you had counselling before, together or separately?Single choiceRequired: Options: Neither of us, ever · Me, on my own · My partner, on their own · Both of us, separately · The two of us together, with somebody else · The two of us together, and it did not go well
Is there anything in the relationship that frightens you, or that you feel you cannot say in front of your partner?Single choiceRequired: Options: No · Yes · I would rather speak to the counsellor privately first
Confidentiality between partnersMultiple choiceRequired: Options: I have read how confidentiality works between partners and agree to counselling on that basis
SignatureSignatureRequired

What each block of this form collects

The identity block asks for the partner name so two separately submitted forms can be matched to one appointment, and it asks for a mobile the partner does not answer and an inbox only the respondent reads. Those two placeholders are doing real work: a couple sharing a phone or an email account cannot be contacted privately, and the practice needs to know that before it sends anything. The relationship block is three structured questions, length, living arrangement and children, which together describe the situation in about fifteen seconds. The why you are here block holds the two open questions and the commitment question. The safety block is one radio with a paragraph above it. The last block is confidentiality, which in couples work is a different thing from confidentiality anywhere else.

How to adapt this form

A family therapy practice adds a household map, every person living in the home with their age and relationship, and replaces the commitment question with one about which relationship in the family is under the most strain. A separation or mediation service keeps the safety screen unchanged, drops the six month goal question and adds property, parenting arrangements and whether legal advice has been taken, since the work there has a different destination. A practice offering discernment counselling for couples where one person is leaning out promotes the commitment question to the top of the form, because in that model it decides which of two completely different processes is offered.

What makes this form work

The contact fields ask for a private channel

A number your partner does not answer, and an inbox only you read. Two placeholders that assume nothing about a shared phone, and give the practice the information it needs before it sends a single reminder.

The safety question has three answers and a paragraph

No, yes, and I would rather speak to the counsellor privately first. Above it, four sentences say everybody is asked, what a yes leads to, and where to go in an emergency. The question only produces true answers because those sentences are there.

Confidentiality between partners is stated before consent

The practice holds no secrets on behalf of one partner, the counsellor will say so openly if asked to carry one, and safety disclosures are handled separately. The tick sits directly under that paragraph, so nobody agrees to a rule they have not read.

Questions people ask

Why does each partner fill in a separate form?

Because a form completed together produces one negotiated story and hides the disagreement, which is the thing the counsellor needs to see. Separate forms also make the safety question answerable. The welcome screen says explicitly not to fill it in together or read it out afterwards, which is the instruction that makes the rest work.

Why ask what the partner would say the problem is?

Because the answer shows how much each person can hold the other's view, which predicts how the work will go more reliably than the complaint itself does. It is optional, and an empty box is informative too. A counsellor reads the two answers side by side before the first session.

What happens if somebody answers yes to the safety question?

The counsellor arranges an individual conversation before any joint session, which the paragraph above the question states before it is answered. Couples work is not appropriate where one person is afraid of the other, so the answer changes what is offered rather than being held against anybody or repeated in the room.

Why does the commitment question have six answers?

Because committed and wanting it to work is a different piece of work from already decided and wanting to end it well, and both are real reasons to book. The sixth option, I would rather say this in the session, is the pressure valve that keeps the other five honest for somebody not ready to type it.

How is confidentiality different in couples counselling?

The client is the relationship rather than either person, so this practice holds no ongoing secret on behalf of one partner. The paragraph says the counsellor will not repeat what is on the form but will also not carry a secret through the work, and that safety disclosures are handled separately. The tick records that this was read.

Can one partner send their form before the other?

Yes, and the thank you screen says the first session goes ahead regardless. Waiting for both would mean the appointment is held hostage by whoever is least keen, which in couples work is usually the person the session most needs to reach.

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Couples counselling intake form, one form for each partner