Couples Therapy Intake Form Please answer each question as completely and accurately as possible. Full NameAgeYears TogetherRelationship StatusWhat are the things you like most about your relationship?What are the things you most want to change?How often to do you argue?What do you most often argue about?Describe your most recent argument. How did it start? How did it end?When you do argue, does someone end up leaving? Who? How long before they come back?How long do you stay mad at eachother?Who is the first to attempt to make things better?Do your arguments ever get physical?Who initiates sex most often?To whom did you go to for comfort when you were young? Could you always count on this person for their comfort? What did it look like when comforted? How did you behave when asking for comfort?Describe any substance use and your partners. Is this a problem in the relationship?Has there been any infidelity in the relationship? If so, please describe.I am _____ % committed to this relationshipI am ______ satisfied in this relationship.Signature *Your browser does not support e-Signature field.Send MessageSave as DraftPlease do not fill in this field.