EBHS Couples Intake Form Please enable JavaScript in your browser to complete this form.Your NameFirstLastDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Who Your If Your EmailYour PhonePartner NameFirstLastPartner EmailPartner PhoneCurrent relationship statusSingleMarriedDivorcedSeparatedWidowedIn a relationship / PartneredPrefer not to sayWho do you live with?Do you have children?YesNoIf yes, what are their ages?Education levelLess than high schoolHigh school diploma / GEDSome collegeAssociate degreeBachelor’s degreeMaster’s degreeDoctorate / Professional degreePrefer not to sayOccupationWhat brings you in for couples therapy?Primary concerns (communication, trust, conflict, intimacy, etc.)What symptoms are you experiencing (anxiety, sadness, anger, stress, etc.)How long have you been experiencing these concernsAny relevant mental health history or diagnoses (for either partner)?Safety concerns (domestic violence, coercion, self-harm, or harm to others)How severe are these concerns on a scale of 1-10What situations tend to make these concerns worseHow would you describe your family relationships?Is there a history of mental health issues in your family?What do you hope to gain from therapy?What changes would you like to see in your life?How will you know therapy is helping?Signature * Clear Signature Submit
