Indy Counseling Professionals



Couples Questionnaire (each partner to complete forms)0264795Please fill out this form with the understanding that it will be shared with your partner or spouse. You can choose to share before the next session but answers maybe taken out of context of a therapeutic perspective.00Please fill out this form with the understanding that it will be shared with your partner or spouse. You can choose to share before the next session but answers maybe taken out of context of a therapeutic perspective.Name: Current issue (s) from your perspective: Past issues? What outcome (s) are you hoping for from counseling?: What are the current stressors or challenges that you or your partner are facing?:Relationship HistoryYour relationship status before this relationship? [ ] Single [ ] Married /Dating another [] Divorced [ ] WidowedPlease give a brief explanation of any significant previous relationships/patterns/abuse…CURRENT PARNTER/SPOUSEHow did you meet?What drew you to your partner?Please describe the best time in your relationship. When was it? What made it work so well?Please list if you have children….NameAgeCo-ParentRelationship QualityFamily of Origin Family Member/NameAgeOccupationRelationship QualityPlease share significant family history (parenting style, economic status, living arrangements, military, health, abuse, and/or family conflict: Please share family traditions, values, life lessons, positive memories that you carry with you today:Personal and Relationship Challenges and StrengthsAre you optimistic that your relationship can be strengthened? [ ] Yes [ ] No [ ] UncertainPlease list any current symptoms, challenges or issues that are impacting your relationship? See first questionWhat strengths do you bring to your relationship?What are your partner’s strengths in the relationship?Please explain possible traits/behaviors of YOURS that may bother your partner or trigger issues:Please share possible traits/behaviors of your PARTNER can bother you or trigger conflict: Anything else to share?Please rate the following questions with a value from 1 to 10.1=Extremely Unsatisfied- 5=Content- 10= Extremely Satisfied; NA= Not ApplicableCURRENTLY...1. How happy I feel in my relationship6. Level of emotional intimacy 2. Degree to which I feel valued by my partner7. Management of household 3. Manner with which we communicate8. Management of finances 4. Quality of physical intimacy9. Cohesiveness of Parenting 5. Frequency of physical intimacy10. Cohesiveness in overall decisions Improving communication is one of the number one reasons couples come to counseling. There are certain principles that allow couples to communicate more openly and “reasonably” that often have to do with individual traits and issues that aren’t aligned well. Communication is impacted by the family styles we grow up in, unshared values and goals, how we are dealing with our own life/personal issues and unawareness of our own personal triggers. As a counselor I find it’s our own triggers and defensive mechanisms that cause us the most difficulty in our relationships. Couples can reinforce or incite these triggers without intending to (dynamics and circular causality). Reconstructing this starts with each person assessing where they can make change and sensitivity to the other persons triggers. Please review what you have already written and see if there are any other triggers that you could include.... Please list triggers or “hot buttons”....What is your reaction when they are pushed (fight, flight or freeze)? Describe...What is your partner’s way of handling conflict?Anything else to add?PLEASE REVIEW THIS FORM TO MAKE SURE THERE IS NOTHING OFFENSIVE TO YOUR PARTNER BEFORE IT IS SHARED. HIGHLIGHT OR NOTE ANY INFORMATION THAT MAYBE UNKNOWN TO YOUR PARTNER SO THAT IT CAN BE ADDRESSED IN A THERAPUETIC MANNER. ................
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