Skip to content
Peaceinbloom
Home
About
Services
Individual Counseling
Couples Counseling
Parenting support
Youth Counseling
Contact
Menu
Home
About
Services
Individual Counseling
Couples Counseling
Parenting support
Youth Counseling
Contact
Book Appointment
Clients portal
Home
About
Services
Individual Counseling
Couples Counseling
Parenting support
Youth Counseling
Contact
Menu
Home
About
Services
Individual Counseling
Couples Counseling
Parenting support
Youth Counseling
Contact
Appointment
Clients Portal
Basic Information
Partner 1 Full Name:
*
Partner 2 Full Name:
*
Preferred Pronouns for Both Partners:
Contact Information
Email Address
*
Phone
*
How did you hear about us?
*
Relationship Background
How long have you been together?
*
What is your relationship status? (e.g., dating, engaged, married, separated, cohabitating, other)
*
Do you live together?
*
Yes
No
Do you have children together or from previous relationships? If yes, please provide their ages.
*
Current Challenges
What are the primary concerns that brought you to couples therapy? (Examples: communication issues, trust, intimacy, parenting conflicts, financial disagreements)
*
Have you experienced significant changes or stressors in your relationship recently? (Examples: relocation, job changes, infidelity, loss of a loved one, health issues)
*
Are there recurring conflicts or patterns that feel difficult to resolve?
*
Goals and Expectations
What would you like to achieve through couples therapy? (Examples: better communication, rebuilding trust, emotional reconnection, conflict resolution skills)
*
What do you both feel is working well in your relationship right now?
*
What has worked for you in the past when resolving disagreements or navigating challenges?
*
Individual Context
Have either of you participated in individual or couples therapy before? If yes, what was helpful or unhelpful about the experience?
*
Are there individual challenges (e.g., mental health, work stress, trauma) that may be affecting your relationship?
*
Additional Information
Couples Therapy typically involves a $2,000+ investment. Are you comfortable with this type of investment in your relationship?
*
Is there anything else you’d like us to know about your relationship, goals, or concerns?
*
Submit
Scroll to Top
