Intake form for couples - WISH Mindscience

This form will help me to help you. I can better prepare for our sessions if I have this information here, and it will save us time (and therefore your money) if you fill it out before our first session.

Please do not compare your answers with those of your partner. It is important that I know about your personal opinion on many questions and not the agreed opinion of you as a couple. Also, try to be as honest as possible when filling in the form and answer as many questions as possible. If you feel that answering a question would emotionally overwhelm you, you can of course leave the question unanswered. However, you might let me know if this is the case.

INTAKE - COUPLES (EN)

First name

Last name

Did you or your partner filled out the initial contact form?

YES, I filled out the initial contact form

YES, my partner filled in the initial contact form

NO, neither I nor my partner have filled out the initial contact form

Contact details

Please enter your contact information here. I am required by law to protocol most of this data. I also need some of the data for correspondence and if I need to reach you urgently, e.g. if there has been a change to your appointment at the last minute.

Title

Preferred name

Sex

Personal pronouns

E-mail

Phone/Mobile

Do you live together with your partner?

Yes

Do you live in Austria

Yes

Address line 1

Postcode / Zipcode

Address line 1

Town/city

Postcode / Zipcode

Address Line 1

County

Country

A. Demographic information

A1. How old are you?

A2. What is your ethnicity / cultural background?

A3. What is the highest level of education you have completed?

A4. Which of the following best describes your main work status over the last twelve months?

A5. What is your profession?

B. Family status

B1. Which of the following best describes your family status?

B2. How often have you been married?

B3. Do you have children with your partner?

Yes

Please list all your children here with their names and ages in the order of their age with the eldest first. Click on the plus sign to add a child/age.

Child's name

Child's age

B4. Do you have children from previous relationships?

Yes

Please list all your children here with their names and ages in the order of their age with the eldest first. Click on the plus sign to add a child/age.

Child's name

Child's age

B5. Please provide information on where your children are living

B6. How old were you when your first child was born?

C. Information about your relationship

C1. How long have you been in your current relationship?

C2. Type of relationship

D. Marital history

D1. What age were you when you first got married?

D2. At the time of your first marriage did you yourself choose your husband/wife?

D3. At the time of your first marriage if you did not choose your spouse yourself, did you give your consent to the choice?

E. Romantic relationship quality

E1. How would you rate the quality of your relationship?

E2. How would your partner rate the quality of your relationship?

The questions in this section relate to the perceived quality of your relationship. Please answer them with the following scale from 1-5 where,

1 = Always;

2 = Usually true;

3 = Sometimes true;

4 = Rarely true;

5 = Never true.

E3. The following questions are about how ACCESSIBLE your partner is to you from your viewpoint

	1	2	3	4	5
I can get my partner’s attention easily.
My partner is easy to connect with emotionally.
My partner shows me that I come first with him/her.
I am not feeling lonely or shut out in this relationship.
I can share my deepest feelings with my partner and he/she will listen.

E4. The following questions are about how ACCESSIBLE you are for your partner from your viewpoint

1 = Always;

2 = Usually true;

3 = Sometimes true;

4 = Rarely true;

5 = Never true.

	1	2	3	4	5
It is easy for my partner to get my attention.
I am emotionally very open, and it is easy for my partner to build an emotional connection to me.
I show my partner that they come first with me.
I make sure that my partner does not feel lonely or shut out in this relationship.
My partner can share their deepest feelings with me, and I will listen.

E5. The following questions are about how RESPONSIVE your partner is to you from your viewpoint

1 = Always;

2 = Usually true;

3 = Sometimes true;

4 = Rarely true;

5 = Never true.

	1	2	3	4	5
If I need connection and comfort, he/she will be there.
My partner responds to signals that I need him/her to come close.
I find I can lean on my partner when I am anxious or unsure.
Even when we fight or disagree, I know that I am important to my partner and we will find a way to come together.
If I need reassurance about how important I am to my partner, I can get it.

E6. The following questions are about how RESPONSIVE you are to your partner from your viewpoint.

1 = Always;

2 = Usually true;

3 = Sometimes true;

4 = Rarely true;

5 = Never true.

	1	2	3	4	5
If my partner needs connection and comfort, I will be there.
I respond to signals that my partner needs me to come close.
My partner can lean on me when they are anxious or unsure.
Even when we fight or disagree, I show my partner that they are important to me and we will find a way to come together.
If my partner needs reassurance about how important they are to me, they can get it.

E7. The following questions are about how emotionally ENGAGED you are with your partner from your viewpoint

1 = Always;

2 = Usually true;

3 = Sometimes true;

4 = Rarely true;

5 = Never true.

	1	2	3	4	5
I feel comfortable being close to and trusting my partner.
I can confide in my partner about almost anything.
I feel confident, even when we are apart, that we are connected to each other.
I know that my partner cares about my joys, hurts and fears.
I feel safe enough to take emotional risks (e.g. talking about shame, fear, etc.) with my partner.

E8. The following questions are about how emotionally ENGAGED your partner is with you from your viewpoint.

1 = Always;

2 = Usually true;

3 = Sometimes true;

4 = Rarely true;

5 = Never true.

	1	2	3	4	5
My partner feels comfortable being close to and trusting me.
My partner can confide in me about almost anything.
My partner feels confident, even when we are apart, that we are connected to each other.
My partner knows that I care about their joys, hurts and fears.
My partner feels safe enough to take emotional risks (e.g. talking about shame, fear, etc.) with me.

F. Health information

These questions relate to your mental and physical health

F1. Are you currently receiving psychiatric treatment?

Yes

F1a. Name of your psychiatrist

F2a. Are you currently taking any prescription psychiatric medication?

Yes

F2b. Please list what medication you are taking for what symptoms. You can add further medication/symptoms by clicking on the plus symbols.

Medication

Symptom(s)

F2c. Do you stick to the quantities prescribed by the doctor?

Yes

F2c(i). What do you do differently?

F3a. How would you rate your current sleeping habits on a scale of 1-10?

Very bad Excellent
0	1	2	3	4	5	6	7	8	9	10

F3b. Please describe any specific sleep problems you are currently experiencing.

F4. How would you rate your physical health on a scale of 1-10?

Very bad Excellent
0	1	2	3	4	5	6	7	8	9	10

F4a. Are you currently suffering from chronic pain?

Yes

H4a(i). Please list the parts/areas of your body where you feel pain. You can click on the plus symbol to add more.

F4b. Please provide further information about any other physical problems that are causing you difficulties.

F4c. How many times a week do you usually exercise?

F5. How would you rate your current eating habits on a scale of 1-10?

Sehr schlecht Hervorragend
0	1	2	3	4	5	6	7	8	9	10

F5s. Please provide further information about any problems with eating or appetite that you are currently experiencing.

F6. On a scale of 1-10, how satisfied are you with your life overall?

Things are terrible Could not be better
0	1	2	3	4	5	6	7	8	9	10

F6a. For approximately how long has it been like this?

F6b. Are you currently experiencing overwhelming sadness, grief or depression?

Yes

F6b(i). Please provide more information on known reasons for this.

F6c. Are you currently experiencing anxiety, panic attacks or have any phobias?

Nein

F6c(i). Please provide more information on known causes and triggers.

F7. Do you drink alcohol?

Yes

F7a. How would you describe your alcohol consumption?

F8. Do you engage in recreational drug use?

Yes

F8a. How often?