Skip to main content

Ultimate, Mother-of-All COUPLES INTAKE QUESTIONNAIRES, V2

Follow
Ryan Buchmann, MA, MFT, CADC-II
  • Edited

I work with a few employee assistance programs (EAP) and they have been starting to refer couples to me.  My intake questionnaire for individuals was simply not inclusive enough.  So, with some modifications on the Mother-of-All Intake Questionnaires, I created the attached. 

05-26-21 V2 Update:  I just added questions pertaining to infidelity, religion and spirituality, cultural issues, gender and sexual identity, and relationship violence issues.  Thank you, Susan Diamond, for the great suggestions!

Please note any checkbox that is clicked will prompt a multi-line text box for more information.   If you can think of anything you believe would be worth adding, please let me know.  If you want the form shared in Simple Practice, vote for it by clicking the heart icon to the left of my picture:

https://drive.google.com/file/d/1vYMjetDu0Ej3ag_mqkyeAnO3EL0LJzN5/view?usp=sharing 

47

Comments

9 comments

Date Votes
  • Joshua Cress

    WOW! The name does not disappoint! This is fantastic, very thorough and clinically helpful. Is there a way to add this to our portal? -Josh

    0
    Comment actions Permalink
  • Ryan Buchmann, MA, MFT, CADC-II
    • Edited

    Not yet. I suggest downloading the PDF and copy/pasting text to the form you can create in your SP account.  Remember, when writing your questions, make sure they are as strength-based as possible.  For example, how would you rephrase the question "Has there ever been a history of abuse or domestic violence in the relationship?" so that it is more strength-based or less threatening?  For example, "Has your partner ever caused you to feel afraid of him/her or hurt your feelings?"  OR "What have you seen happen when your partner gets really angry?" OR "What have you noticed causes your partner to become angry at you?"  For those of you who work with DV couples, please share other (or better) question ideas.

    1
    Comment actions Permalink
  • Elizabeth Hocker

    Thanks for sharing! I wish this was one that SP could upload!

    0
    Comment actions Permalink
  • Gina M. Mills LCSW, LLC

    Thank you for sharing this!  I would vote if I knew how!

    0
    Comment actions Permalink
  • Martha J. Johnson

    Thank you 

    0
    Comment actions Permalink
  • Lina Pranata, Ph.D.

    Thank you for sharing this. 

     

    0
    Comment actions Permalink
  • Marian M. Steele-Murray

    Thank you! Great help

    0
    Comment actions Permalink
  • Susan Diamond

    This is great, Ryan. Thank you. I'm not seeing the heart icon, but would vote for it if I could. I'd like to have questions added about how the couple's relationship is impacted by religious/ spiritual beliefs, cultural influences, and any factors related to gender identity or sexual orientation. I'd also like to know about history of trauma for either person. Finally, for reasons for seeking therapy, perhaps something about increased trust and/or navigating the impact of an infidelity.

    0
    Comment actions Permalink
  • Ryan Buchmann, MA, MFT, CADC-II

    Thanks, Susan Diamond, for these great suggestions.  I added them to the questionnaire and created V2.  I hope it meets your needs.

    0
    Comment actions Permalink

Please sign in to leave a comment.

Didn't find what you were looking for?

New post