Counselling Intake Form

Counselling Intake Form

Welcome to FamilyLife NZ Counselling Services. We are delighted that you have chosen to work with us and excited to begin our journey together.

To better serve you, please fill out the below form as accurately as possible. Thank you.

Your name*
First Last
Email*
Phone*
Area of residence*
Your partner's name*
First Last
Emergency contact name*
First
Emergency contact phone number*
Relationship with partner*
- Married
- Separated
- Divorced
- Dating
- Cohabitating
- Living together
- Living apart
Length of time in current relationship:
Have you received prior couples counselling?*
When
Where
By whom
Length of treatment
Problems treated
What are your biggest strengths as a couple?
What are the qualities that initially attracted you to your partner?
Rank order the top three concerns that you have in your relationship with your partner (1 being the most problematic):
What do you hope to accomplish through our counselling session?*
Are you open to online counselling?*
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