Couples Counselling Form

Please review the couples counselling preparation form below, prior to attending your couples therapy.

We request this is completed 24 hours before your session, which allows us to prepare for your session however If you feel uncomfortable filling out certain parts of this form, please enter N/A.

Your details

Date

Your Name(Required)

First Last

D.O.B(Required)

Phone(Required)

Email(Required)

Your Address(Required)

Street Address Address Line 2 City Zip/ Postal Code

G.P. Surgery name(Required)

G.P. Surgery phone number(Required)

G.P. Surgery Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Therapist Name

Your relationship

Partner Name

What are your main concerns?(Required)

Status of your relationship. Length of time in this relationship?(Required)

Married couples: How long were you both dating prior to getting married? Did you live together before marriage, if so, how long for?

Previous relationships (long term) how you meet, length of time, who broke up the relationship and why:(Required)

Have you had couples’ therapy or individual therapy before, if so please identify what you liked or disliked?(Required)

How would you describe your history from the start of your relationship to the present moment?(Required)

What are important beliefs for you, that you both have in common? What beliefs do you both not share?(Required)

What did you envisage the relationship to be, when you first met? Has this changed and if so, how?(Required)

What kind of relationship do you want to be in? What do you need to do to make that happen?(Required)

List the barriers you bring to the relationship you want and any changes you've identified you need to make(Required)

What are some of the things you would need to see that will help you to know you’re on the right track with the changes your making?(Required)

What do you need to let go off for you to be the partner you want to be?(Required)

How do you resolve conflicts? How does your partner resolve conflicts?(Required)

What traits does your partner have that you find challenging? Which of your traits does your partner find challenging?(Required)

Any previous or current issues of domestic violence?(Required)

Do either you or your partner currently have an issue with alcohol or drugs?(Required)

How easy or difficult do you find it to express your feelings, thoughts, desires and values to your partner?

Family history

Parents relationship status(Required)

If your parents separated from each other or remarried/entered into new partnerships, how old were you at the time?

Relationship with parents as a child and now – mother:(Required)

Relationship with parents as a child and now – father:(Required)

How many siblings do you have and briefly describe your relationship with them:

Trigger warning. Is there any abuse (physical/sexual/verbal) you’ve experienced in your family or at any stage on your life?

I agree to the terms and conditions and the fee set out when booking my appointment. Click Here To View The T&C's

Signature(Required)

Get In Touch

71 Vyse Street, Jewellery Quarter, Birmingham, B18 6EX

Email Company

Enquiries@Kayscounselling.co.uk

Time Open

Mon - Fri 9am to 9pm Sat - Sun 9am to 3pm

We Are Support 24/7

01216796200

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We are a Integrative Counselling Clinic in Birmingham City Centre, we are here to listen and help you overcome your issues.