Ý Marital/Relationship Counseling Information Form

The Family Resource Center

Return form by faxing to (281) 444-0368 or by emailing to jagvw@earthlink.net

ÝÝÝ 1)Ý Name: ÝÝÝ 2)Ý Age: ÝÝÝ 3)Ý Date:

ÝÝÝ 4) Address: ÝÝÝ City: ÝÝÝÝÝÝÝÝÝÝ ÝÝÝState: ÝÝ Zip:

ÝÝÝ 5)Ý Briefly, what is your main purpose in coming to marital therapy?

Instructions: To assist us in helping you, please fill out this form as fully and openly as possible. Your answers will help plan a course of marital therapy that is most suitable for you and your spouse. Do not exchange this information with your spouse.

Several of your answers on this form may be shared later with your spouse during joint therapy sessions if you give us permission to share this information. For this reason you are advised to respond honestly and carefully to each item. If certain questions do not apply to you or you do not want to share this information, please leave them blank.

ÝÝ 6)Ý Is this your first marriage? ÝYesÝÝÝ ÝNo

ÝÝÝÝÝÝÝÝÝÝ If No, which marriage is it for you? 2 3Ý 4 5+

ÝÝÝ 7)Ý How long have you and your present spouse been married?

ÝÝÝ 8)Ý Are you and your spouse presently living together? ÝYesÝÝÝ Ý ÝNo

ÝÝÝÝÝÝÝÝÝÝ If No, why not?

ÝÝÝ 9)Ý How many times have you and your spouse separated?

Ý 10)Ý Fill out the following information for each child of whom the natural parent is both you and your partner, children from previous relationships, and adopted children.

ÝÝÝÝÝÝÝ ÝÝÝÝ *ìWhose child?î answering options:ÝÝÝ BÝÝÝ =ÝÝÝ Both of ours, natural child

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝ BAÝÝÝ =ÝÝÝ Both of ours, adopted (or taken on)

ÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝ MÝÝÝ = My natural child

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝ MAÝÝÝ = My child, adopted (or taken on)

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ SÝÝÝ =ÝÝÝ Spouseís natural child

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝ SAÝÝÝ =ÝÝÝ Spouseís child, adopted (or taken on)

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ *WhoseÝÝÝ Lives with

ÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Childís nameÝÝÝÝÝÝÝÝÝÝ AgeÝÝÝÝÝÝÝÝÝÝ SexÝÝÝÝÝÝÝÝÝÝ child?ÝÝÝÝÝÝÝÝÝÝ you and spouse?

ÝÝÝÝÝÝÝÝÝÝ 1)ÝÝÝ Ý ÝÝÝÝ Ý ÝÝÝÝ F M Ý ÝÝ ÝÝÝÝ ÝÝÝÝ ÝYesÝÝÝ ÝNo

ÝÝÝÝÝÝÝÝÝÝ 2)ÝÝÝ Ý ÝÝÝÝ Ý ÝÝÝÝ F M ÝÝ ÝÝÝÝ ÝÝÝÝ ÝYesÝÝÝ ÝNo 3) Ý ÝÝ ÝÝÝÝ Ý ÝÝÝÝ F M ÝÝ ÝÝÝÝ ÝÝÝÝ ÝYesÝÝÝ ÝNo

ÝÝÝÝÝÝÝÝÝÝ 4)ÝÝÝ Ý ÝÝÝÝ Ý ÝÝÝÝ F M ÝÝ ÝÝÝÝ ÝÝÝÝ ÝYesÝÝÝ ÝNo

ÝÝÝÝÝÝÝÝÝÝ 5)ÝÝÝ Ý ÝÝÝÝ Ý ÝÝÝÝ F M ÝÝ ÝÝÝÝ ÝÝÝÝ ÝYesÝÝÝ ÝNo

ÝÝÝÝÝÝÝÝÝÝ 6)ÝÝÝ Ý ÝÝÝÝ Ý ÝÝÝÝ F M ÝÝ ÝÝÝÝ ÝÝÝÝ ÝYesÝÝÝ ÝNo

ÝÝÝÝÝÝÝÝÝÝ 7)ÝÝÝ ÝÝÝÝ Ý ÝÝÝÝ F M ÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝYesÝÝÝ ÝNo

ÝÝÝÝÝÝÝ 8) ÝÝÝ ÝÝÝÝ Ý ÝÝÝÝ F M ÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝYesÝÝÝ ÝNo

Ý 11)Ý List five qualities that initially attracted you to ÝÝÝ Does your spouse still

ÝÝÝÝÝÝÝÝÝÝ your spouse:ÝÝÝ ÝÝÝ possess this trait?

ÝÝÝÝÝÝÝÝÝÝ 1)ÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝYesÝÝ ÝNo

ÝÝÝÝÝÝÝ 2)ÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝYesÝÝ ÝNo

ÝÝÝÝÝÝÝ 3)ÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝYesÝÝ ÝNo

ÝÝÝÝÝÝÝÝÝÝ 4)Ý Ý ÝÝ ÝÝÝÝ ÝÝÝÝ ÝYesÝÝ ÝNo

ÝÝÝÝÝÝÝ 5)ÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝYesÝÝ ÝNo

Ý 12)Ý List four negative concerns that you initially ÝÝÝ Does your spouse still

ÝÝÝÝÝÝÝÝÝÝ had in the relationship:ÝÝÝ ÝÝÝ possess this trait?

ÝÝÝÝÝÝÝÝÝÝ 1)ÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝYesÝÝ ÝNo

ÝÝÝÝÝÝÝ 2)ÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝYesÝÝ ÝNo

ÝÝÝÝÝÝÝ 3)ÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝYesÝÝ ÝNo

ÝÝÝÝÝÝÝÝÝÝ 4)Ý Ý ÝÝ ÝÝÝÝ ÝÝÝÝ ÝYesÝÝ ÝNo

13) List five present positive attributes ofÝÝÝÝÝÝ ÝÝÝ

ÝÝÝÝÝ 1) ÝÝÝÝÝÝÝÝÝÝÝ ÝYesÝÝ ÝNo

ÝÝÝÝÝÝÝ 2)ÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝYesÝÝ ÝNo

ÝÝÝÝÝÝÝ 3)ÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝYesÝÝ ÝNo

ÝÝÝÝÝÝÝÝÝÝ 4)Ý Ý ÝÝ ÝÝÝÝ ÝÝÝÝ ÝYesÝÝ ÝNo

ÝÝÝÝÝÝÝ 5)ÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝ ÝYesÝÝ ÝNo

Do you often praise your spouse: ÝÝÝÝ spouse for this trait?

ÝÝÝÝÝÝÝÝÝÝ

Ý 14)Ý List five present negative attributes ofÝÝÝ ÝÝÝ Do you nag your spouse

ÝÝÝÝÝÝÝÝÝÝ your spouse:ÝÝÝ ÝÝÝ about this trait?

ÝÝÝÝÝÝÝ 1) ÝÝÝÝÝÝÝÝÝÝÝ ÝYesÝÝ ÝNo

ÝÝÝÝÝÝÝ 2)ÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝYesÝÝ ÝNo

ÝÝÝÝÝÝÝ 3)ÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝYesÝÝ ÝNo

ÝÝÝÝÝÝÝÝÝÝ 4)Ý Ý ÝÝ ÝÝÝÝ ÝÝÝÝ ÝYesÝÝ ÝNo

ÝÝÝÝÝÝÝ 5)ÝÝÝ