Emily Suzanne Shields, LMHC



Up the Creek CounselingCounselors: Scott Wright and Emily ShieldsCouples Counseling Initial Intake FormName:_________________________________________________ Date: __________________Name of Partner:________________________________________Relationship Status: (check all that apply)□ Married□ Separated□ Divorced□ Dating□ Cohabitating□ Living together□ Living apartLength of time in current relationship: _______________Do you have children? If so, how many? _____ Girls ______BoysHave you ever lost a child or pregnancy?________________________________Are you aware of any major losses, accidents, or other traumatic incidents in your family?___________________________________________________________________________________________________________________________________________________________________________________________________________________________How would you rate your level of concern about your relationship issues currently?□ No concern□ Little concern□ Moderate concern□ Serious concern□ Very serious concernHow frequently do your current issues cause strain, arguments, or tension in your relationship?□ No occurrence□ Occurs rarely□ Occurs sometimes□ Occurs frequently□ Occurs nearly alwaysWhat do you hope to accomplish through counseling?___________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you taken any steps to solve your problems together? If so, what have you tried?___________________________________________________________________________________________________________________________________________________________________________________________________________________________What are your biggest strengths as a couple?___________________________________________________________________________________________________________________________________________________________________________________________________________________________Please rate your current level of relationship happiness.1 2 3 4 5 6 7 8 9 10(extremely unhappy) (extremely happy)Have you received prior couples counseling related to any of the above problems? □ Yes □ NoIf yes, when: _____________________________ Where:_______________________________With whom: _______________________________ Length of treatment:_______________Issues worked on: ___________________________________________________________________________________________________________________________________________What was the outcome (check one)?□ Very successful □ Somewhat successful □ Stayed the same □ Somewhat worse □ Much worseHave either you or your partner been in individual counseling before? □ Yes □ NoIf so, give a brief summary of concerns that you addressed.___________________________________________________________________________________________________________________________________________________________________________________________________________________________Do either you or your partner drink alcohol to intoxication or take drugs to intoxication? If yes for either, who, how often and what drugs or alcohol?___________________________________________________________________________________________________________________________________________________________________________________________________________________________Have either you or your partner struck, physically restrained, used violence against or injured the other person? If yes for either, who, how often and what happened.___________________________________________________________________________________________________________________________________________________________________________________________________________________________Has either of you threatened to separate or divorce (if married) as a result of the current relationship problems?If yes, who? ___Me ___Partner ___Both of usIf married, have either you or your partner consulted with a lawyer about divorce?If yes, who? ___Me ___Partner ___Both of usDo you perceive that either you or your partner has withdrawn from the relationship?If yes, which of you has withdrawn? ___Me ___Partner ___Both of usHow frequently have you had sexual relations during the last month? ________timesHow enjoyable is your sexual relationship? (Circle one)1 2 3 4 5 6 7 8 9 10(extremely unpleasant) (extremely pleasant)How satisfied are you with the frequency of your sexual relations? (Circle one)1 2 3 4 5 6 7 8 9 10(extremely unsatisfied) (extremely satisfied)What is your current level of stress (overall)? (Circle one)1 2 3 4 5 6 7 8 9 10 (no stress) (high stress)What is your current level of stress (in the relationship)? (Circle one)1 2 3 4 5 6 7 8 9 10 (no stress) (high stress)What do you think are the three biggest problems in your relationship?1. _____________________________________________________________________2. _____________________________________________________________________3. _____________________________________________________________________What are the three biggest stressors for you personally?1. _____________________________________________________________________2. _____________________________________________________________________3. _____________________________________________________________________At what point in your relationship do you recall being happiest with your partner? __________________________________________________________________________________________________________________________________________________When did your current relationship problems begin? __________________________________________________________________________________________________________________________________________________Thank you for completing this form. Please bring this with you during your first appointment. Please note that you will be asked to talk about your answers in sessions but your partner will not be shown this form.Adapted from Couples Counseling Intake Form by Cory Montfort, MS, LPC. ................
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