Couples Therapy Questionnaire

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New Couples Therapy Questionnaire

First Name

Last Name

Select a therapist with whom you have an appointment.

David Pearl, LCSW Rachel Fleischer, LPC-MHSP Hope Spector, LPC-MHSP Campbell Bowden, LPC (temp)

What would you most like to get out of our work together?

Describe your previous Individual or Couples therapy experience if you have had any:

Attraction Phase: Describe falling in love with your partner. What were the traits they possessed that made you decide to connect with them?

Power Struggle: (Things changed when...)

What do you imagine it is like being married to/in relationship with you?

What are the strengths of this relationship?

What, if any, Medication(s) are you taking?

Alcohol & Drug History:

Is there anything else I need to know about you and your relationship that would be important so that I can be the most helpful? Remember, I cannot hold secrets from your partner, but I can help you tell them things you might be afraid to tell them.

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New Couples Therapy Questionnaire

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