Marital Intake Form

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MaleFemale


CaucasianAfrican-AmericanHispanicNative AmericanAsianOther


Some High SchoolHigh School GraduateSome CollegeCollege GraduateSome Graduate SchoolAdvanced Degree Graduate


12345678910


12345678910





CatholicProtestantJewishOther


1 - Not at all2345 - Somewhat678910 - Very Important











Together in the same houseTogether in the same house, separate roomsSeparated, not pursuing divorceSeparated, pursuing divorce


1 - Divorcing2- Weakening3 - Indifferent/Committed4 - Solid5 - Absolutely




Clinical PsychotherapyPastoral CounselingEnrichment WeekendOther


1 - Not Satisfied23 - Somewhat Satisfied45 - Very Satisfied


Alcohol/drugsAngerMotivationBothersome HabitsCareer decisionsDepressionStress/anxietyLonelinessFear of futureLoss/grief/deathConfusionLegal IssuesFamily conflictAbortionRapeAssertivenessSelf ConfidenceSelf ImageSocial skillsPornographyGamblingSuicidal ideasSexualityPhysical healthSleepWeight loss/gainHallucinationsDelusionsDecision MakingObsessionsOther

Please provide the following information concerning your parents.














Mainly me who is interestedBoth of us equally interestedMainly spouse is interested


Not hopeful at allA little hopefulIndifferentHopefulExtremely hopeful




YesNo


YesNo



YesNo