Couple Intake Form

First Name

Middle Name

Last Name

Phone Number

Province

Birthday (DD-MM-YYYY)

Gender

Pronouns

Please describe what has brought you to seek couples therapy at this time?

How are these issues interfering with your relationship functioning and how long have you been experiencing this disconnection?

How aware or in touch with your emotions are you? (1 – Low / 10 – High)

How open are you in expressing your innermost feelings, desires and thoughts to your partner? (1 – Low / 10 – High)

Describe your level of commitment to your relationship. (1 – Low / 10 – High)

How much do you still love your partner? (1 – Low / 10 – High)

How much friendship do you feel towards your partner? (1 – Low / 10 – High)

How much do you respect your partner? (1 – Low / 10 – High)

How well do you and your partner resolve conflicts? (1 – Low / 10 – High)

How well do you and your partner manage homelife (chores, bills, cooking, cleaning, etc.)? (1 – Low / 10 – High)

How well do you and your partner share parenting duties? (1 – Low / 10 – High)

Overall, what stressors are negatively impacting your relationship at this time?

Emergency Contact

Physician Name

Physician Contact

Guiding Your Path to Inner Peace

kwasi@peaceuntoyou.ca

admin@peaceuntoyou.ca

Working Hours

Monday – Saturday

9am – 9pm

Sundays – By Appointment Only