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