Name
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First Name
Last Name
Preferred Pronouns
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Email
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Phone
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Birthdate
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Age
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Name
First Name
Last Name
Relationship to You
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Phone
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What is the reason you decided to pursue relational counseling?
Challenging things about your current life & relationship that you want me to know are:
If possible, answer challenges for each person & for the relationship a whole.
Wonderful things about your current life & relationship that you want me to know are:
If possible, answer challenges for each person & for the relationship a whole.
Challenging things from your history that you want me to know are:
Wonderful things from your history that you want me to know are:
How are you similar? How are you different?
What strengths and weaknesses does each one have in resolving conflict?
How do you like to feel supported by those around you?
Describe for each person in the relationship.
On a scale of 1 - 10, 10 = high, how would you rate the quality of your relationship today?
What is your biggest challenge(s) or obstacle(s) in relationship?
Describe what your life might look like if you successfully managed these challenges.
What is one thing you can do personally to improve the quality of the relationship regardless of the others involved?
On a scale of 1-10, 10 = high, what is your current level of stress?
How do you typically deal with stress?
What do you find helps you when you're struggling?
How would you describe your overall health?
Reflections may include diet, sleep, energy management, exercise or movement - mind, body, heart health.
Do you have any current health concerns?
Are you taking any medications?
On a scale of 1-10, 10 = high, how would you describe your daily energy levels?
Describe your use of alcohol and recreational drugs
Have you had any major hospitalizations?
Please include any hospitalizations for emotional reasons / mental health / major surgeries & share to the degree you feel comfortable.
Is there anything that feels important to share about your current living situation?
If currently employed, what is your current employment situation?
On a scale of 1-10, 10 = high, how much do you enjoy your work?
Is there anything stressful about your current work?
What’s your previous experience with therapy / coaching / self help?
How long do you imagine being in relational therapy / counseling / coaching?
What would you like to accomplish in this container?
How can I best support you? What do you most need from me?
Is there anything else you’d like me to know?
Who referred you?
