Basic Information (Partner 2)

Gender Woman Man Non-binary Prefer to self-describe Prefer not to say

Relationship Overview

How long have you been together? Less than 1 year 1-3 years 3-5 years 5+ years What is your current relationship status? Dating Engaged Married Live-in Separated/On a break Other Are both partners aware of and Willing to attend therapy? Yes No Not sure

What Brings You Here?

Communication challenges Frequent conflicts / arguments Emotional distance Trust issues / infidelity Considering a break or separation Rebuilding after a conflict Intimacy concerns Family or external stress impacting relationship Life transitions (moving, jobs, etc.) Differences in expectations or values Other

Current Relationship Wellbeing

(How would each of you rate the relationship currently? )

Partner 1

1 - Struggling a lot 2 - Not doing great 3 - Managing okay 4 - Mostly okay 5 - Doing well

Partner 2

1 - Struggling a lot 2 - Not doing great 3 - Managing okay 4 - Mostly okay 5 - Doing well

How Long Has This Been Going On?

A few weeks A few months 6+ months On and off for years

Therapy History

Have either of you been to therapy? Yes No

What Are You Hoping to Get From Therapy?

Therapist Fit (to help us match you better)

(What kind of support style would you prefer? )

Structured (tools, exercises, goal-oriented) Exploratory (open conversations, reflective) A mix of both Not sure

Practical Details

Preferred session format:

Online Phone In-person Morning Afternoon Evening Weekend

Safety Check (Important)

(Is either partner currently experiencing thoughts of harming themselves or feeling unsafe? )

No Yes

If yes: Please reach out to local emergency services or a crisis helpline. This form is not monitored for emergencies.

Final Question

Consent

We understand this form is for inquiry purposes and not a substitute for emergency mental health support. Request Consultation

How did u hear about us?

Instagram YouTube Referred by a friend Google Other