Couples Questionnaire

Helps therapists better understand a couple's dynamic ahead of a session by gathering information about their relationship and expectations.

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Your Full Name*

First Name

Last Name

Your Email Address*

Partner's Full Name*

First Name

Last Name

Partner's Email Address*

Date of Meeting or Session*

How long have you been together?*

Less than 1 year 1 to 3 years 3 to 5 years 5 to 10 years More than 10 years

Relationship Status*

What are your main goals for this session?

On a scale of 1 to 10, how satisfied are you with your relationship?*

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Do you have any concerns you'd like to discuss?

Communication Finances Intimacy Family Trust Other

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