Date of Birth (Format: mm/dd/yyyy)
---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Phone (Format: 555-555-5555)
Level of Education
Some High SchoolHigh School GraduateSome CollegeCollege GraduateSome Graduate SchoolAdvanced Degree Graduate
My relationship with my partner is more important to me than almost anything else in my life
I want this relationship to stay strong no matter what rough times we may encounter
If retired, what was your occupation?
What is your current occupation?
What is your spouse's occupation?
What is your religious affiliation?
All things considered, how central is your faith to your day to day life?
1 - Not at all2345 - Somewhat678910 - Very Important
How long have you been married to your spouse?
How long were you and your spouse engaged?
Did you live together before you were married? If yes, how long?
Have you been previously married? If yes, how many times?
Have you ever been widowed? If yes, when?
How many children do you have with your spouse?
How many children do you have with your previous spouse?
Please list the ages and gender of your children (Please note if they are step children and whether or not they live with you)
Total number of people living in your home
Please mark the statement that best describes your living situation with your spouse.
Together in the same houseTogether in the same house, separate roomsSeparated, not pursuing divorceSeparated, pursuing divorce
On a scale of 1 to 5, how committed are you to your marriage?
1 - Divorcing2- Weakening3 - Indifferent/Committed4 - Solid5 - Absolutely
In your own words, describe the problems and issues that prompted you to seek therapy.
Have you attended therapy/counseling before? If yes, how many sessions?
Check the type of therapy/counseling you received.
Clinical PsychotherapyPastoral CounselingEnrichment WeekendOther
How satisfied were you with the therapy/counseling you received?
1 - Not Satisfied23 - Somewhat Satisfied45 - Very Satisfied
Please check any topic that you believe is an issue to you or your relationship.
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.
Father's Age (If deceased please include date of death)
Mother's Age (If deceased please include date of death)
Describe your relationship with your Father.
Describe your relationship with your Mother.
List your siblings in birth order. Name - Age - Living? - Occupation
Describe how you were disciplined growing up.
In your own words, describe your parents’ marital relationship.
Were you raised in a step or blended family? If yes, how many years?
In your estimation, who is more interested in coming to therapy/counseling?
Mainly me who is interestedBoth of us equally interestedMainly spouse is interested
How hopeful are you about achieving a satisfying marriage through therapy/counseling?
Not hopeful at allA little hopefulIndifferentHopefulExtremely hopeful
Do you or your spouse have any chronic health conditions or disabilities? If yes, please describe the chronic conditions.
Please list the medications you are currently taking.
Has your spouse or close friend ever indicated that you have a problem with alcohol or drugs?
Does your spouse have a problem with alcohol or drugs?
Do you use alcohol or drugs on a weekly basis? If yes, indicate what you use and how much on a daily/weekly basis.
Did one or both of your parents use alcohol or drugs?
In your marriage, what is your goal or hope at this time?
What initially attracted you to your partner?
In your couple history, when do you believe the relationship was the most satisfying? Why?
How did you decide to get married?
Describe how you believe problems developed in the marital relationship and what you have tried to correct the problems.
How are you and your spouse similar?
How are you and your spouse different?
What activities do you and your spouse engage in together?
What activities do you engage in by yourself?
What would your spouse say is the main problem in the marriage?
Please give us any information that you feel is pertinent in preparation for counseling.
TEXAS · CALIFORNIA · GEORGIA
4211 I-40 West · Suite 202 · Amarillo, TX 79106 · (806) 290-0055
© 2019 The Hideaway Experience.