Couples Therapy Intake Form

Collects contact details and relationship history from both partners before a first couples therapy session. Gives the therapist a starting picture of what each person hopes to work on and what has already been tried.

Use this template

In the Claude connectors directory

Partner 1 Name

First Name

Last Name

Partner 2 Name

First Name

Last Name

Partner 1 Phone Number

Partner 2 Phone Number

Partner 1 Email Address

Partner 2 Email Address

Address

Street Address

City

State / Province

ZIP / Postal Code

How long have you been in the relationship?

Have you had couples therapy before?

What have you tried in the past to resolve your issues?

Partner 1: What do you think your relationship needs the most help with?

Partner 2: What do you think your relationship needs the most help with?

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