A Depth Psychology Couples Intake Questionnaire for Deep Diving & Reflection

Inspired by the questions posed in Goals for Couples Therapy, I blended my standard couples intake questionnaire with this and perspectives from llyn Bader & Peter Pearson of the Couples Institute. The result? A robust, if not verbose, list with a Depth orientation of questions to freewrite from, consider, and reflect on before or during couples therapy treatment. 

Your Couples Therapy Experience & Expectations

• Have you done couples therapy together before?
• Have you done couples therapy individually, with another partner, before?
• Did you have a positive, neutral, or negative experience? 
• Are there negative connotations you hold about couples therapy?
• Why seek help now? Is there a singular problem, issue, or event that led you to decide to come to couples therapy?
• Whose idea was it to come to therapy?
• What do you want to get out of your sessions?
• What are your expectations for therapy/counseling?

Your Relationship

• How long have you been together and in what capacity?
• If your relationship was a book or a movie, what would it be titled?
• If your relationship was a music band or performer, what would it be?
• What are your biggest strengths as a couple?
• What initially attracted you to your partner?
• What was the beginning of your relationship like and how long did this phase last?
• What happened that first caused you to feel disillusioned with your partner? Did this lead to any changes in your relationship?
• How long has it been since things were good between the two of you? What caused things to go downhill after that?
• Draw a relationship timeline and point out when your relationship satisfaction changed along it from when you first got together until now.
• Name the top three concerns that you have in your relationship with your partner (“1” being the most problematic):
• What issues have your relationship been through in the past?
• Do you feel on the same page as your partner in terms of what you want out of therapy?
• Do you feel on the same page about what you envision would be a better life together?
• How important is it to you to improve the quality of your relationship?
  (not important) 1 2 3 4 5 6 7 8 9 10 (extremely important)
• How willing are you to make “working on this relationship” a priority in your life? (not willing) 1 2 3 4 5 6 7 8 9 10 (extremely willing)
• Have you reflected on your respective childhood on potential origins of problematic habits?
• What insights, if any, have you gleaned from reflecting on your childhood experiences and conditioning through your own processing so far?
• What role have you played in contributing to the problems in your relationship; what tendencies do you have and what actions have you taken that have helped create or have added to the difficulties between you two?
• Please make at least three suggestions as to something you could personally do to improve the relationship regardless of what your partner does:
  
  

Areas of growth potential and objectives for couples counseling:
□ Improvement of communication
□ Ability to resolve conflicts together
□ Develop/improve co-parenting skills and balance of parenting duties
□ Learn how to problem solve together
□ More intimacy (emotional)
□ More intimacy (sexual)
□ More quality time together
□ Resolution/progress with my individual issues
□ Resolution/progress with my partner’s individual issues
□ More autonomy in my relationship
□ Foster more respect/understanding between us
□ Examine and address power and control issues in relationship
□ More hobbies alone/alone time for yourself
□ More hobbies together/shared activities
□ More social contacts, time with your individual friends
□ More social contacts, shared time with friends
□ More sharing of the chores
□ Help managing household
□ Help with child(ren) behavioral issues

Stress & Coping

• What is your current level of stress (overall)?
  (No stress) 1 2 3 4 5 6 7 8 9 10 (extremely stressed)
• What is your current level of stress in the relationship?
  (No stress) 1 2 3 4 5 6 7 8 9 10 (extremely stressed)
• Are you aware of your own stress response patterns?
• What can trigger reactivity and defensiveness in you?
• Are there any negative coping mechanisms you use (negative coping strategies, such as substance abuse, drinking/eating (too much or too little), nail biting, smoking, becoming aggressive or violent, spending money impulsively, etc.) when stressed or in conflict?
• Please describe any significant or stressful life events that you are experiencing, such as: 

Economic problems? 
Difficulty accessing health care?
Legal issues or crime?
Discrimination? 
Cultural issues?
Transitioning (transgender)?
Family conflict?
Lack of support?
Social problems?
Educational or occupational difficulties?
Housing problems?
Eating disorder? 
Grief or bereavement?
Other:

Substance Use & Habits

• Do either you or your partner drink alcohol or take drugs to intoxication?
  □ Yes □ No If yes for either, who, how often and what types of drugs/alcohol?
• Please describe your current habits in each of the following areas:

Smoking:
Gambling:
Drinking:
Drug use:
Caffeine intake:
Exercise:
Eating:
Sleeping:
Fun and relaxation:

• What are good ways you know how to cope (positive coping strategies that work for you)?

You

• Please list any psychological or physical conditions you have been diagnosed with:
• Have you ever been hospitalized for psychological or psychiatric reasons?
• Medications you currently take:
• On a scale of 1 to 10, how aware or in touch with your emotions are you
  (1=not at all and 10=extremely)? Explain the rating you give yourself.
• How would you describe how you best receive love?
• Please rate your current level of relationship satisfaction by circling the number that corresponds with your current feelings about the relationship:
  (extremely unsatisfied) 1 2 3 4 5 6 7 8 9 10 (extremely satisfied)
• Do you want to be in this relationship? On a scale of 1 to 10, describe your level of commitment to your relationship (1=not at all, 10= extremely). Explain the rating you give yourself.
• What doubts do you have around this relationship?
• What hopes do you have for this relationship?

Sexuality

• How satisfied are you with the frequency of your sexual activities?
  (extremely unsatisfied) 1 2 3 4 5 6 7 8 9 10 (extremely satisfied)
• How satisfied are you with the quality of yours your sexual activities?
  (extremely unsatisfied) 1 2 3 4 5 6 7 8 9 10 (extremely satisfied)
• Do you have sexual trauma in your personal history?
• Is your partner aware of your sexual trauma, if applicable?
• Are you aware of what a sexually satisfying relationship right now would feel like?
• What don’t you like about your sexual relationship right now?
• How has your sexual relationship changed since you were first together?
• Do you feel comfortable talking about sex with your partner in general?
• Do you feel comfortable talking about sex in therapy sessions?
• Do you have concerns or areas of growth, exploration, etc., around sex, sexuality, gender identity, or expression that you want to bring to couples therapy?

Safety, Security & Connection

• Have either you or your partner physically restrained, harmed, or injured the other person? E.g., pushed, shoved, grabbed, or slapped, etc. □ Yes □ No
  If yes for either partner, who, how often and what happened?
• Has either of you threatened to separate/divorce as a result of the current relationship problems? □ Yes □ No. If yes, who? ____Me ___Partner ___Both of us
• If married, have either of you consulted with a lawyer about divorce?
  □ Yes □ No If yes, who? ____Me ___Partner ___Both of us
• Do you perceive that either you or your partner has withdrawn from the relationship?
  □ Yes □ No If yes, who? ____Me ___Partner ___Both of us
• Have you or your partner ever emotionally or physically cheated on each other?
  □ Yes □ No □ Unsure If yes, who? ____Me ___Partner ___Both of us
• How comfortable are you if your partner spends free time away from you?
• Do you enjoy being involved in activities separate from you partner? What do you like to do in those situations?
• When do you feel most content in your relationship?
• When do you feel most unhappy or frustrated?
• Do you know what you need to feel safe in this relationship?
• Do you have a sense of what your partner needs to feel safe, or safer, in this relationship?
• When you could use support or encouragement from your partner, do you get it? How?
• When your partner wants support of encouragement from you do you feel that you give it? How?

Your Partner

• Do you think you are fundamentally compatible with your partner? Do you know what barriers there are to compatibility, if any?
• On a scale of 1 to 10, how much do you still love your partner(1=not at all, 10=very deeply)? Explain the rating you give yourself.
• Are there ways that your partner is different from you that you find particularly hard to deal with, accept, or communicate?
• How are the two or you similar and how are you different?
• Are you aware of your partner’s fears, stress responses, and traumas?
• How would you describe how your partner best receives love?
• On a scale of 1 to 10, how much do you respect your partner (1=not at all, 10=very highly)?
• What is it about your partner that creates that level of respect in you?

Communication

• On a scale of 1 to 10, how open are you in expressing your innermost feelings, desires and thoughts to your partner (1=totally closed and 10=totally open)? Explain the rating you give yourself.
• Are you afraid of your partners’ reactions to you opening up?
• Does your partner listen to you in a way that feels accepted, validated, and understood?
• Do you listen in a way that you believe conveys acceptance, validation, and understanding? 
• What is the area or topic that it is most difficult for you to open with your partner about? Why?  

​Conflict & Resolution

• What do you do when there is conflict between the two of you?
• What does your partner do?
• Are there unresolved conflicts in your relationship?
• Do you believe these conflicts have the potential to be resolved, ultimately? Why or why not?
• How do you want to see your relationship grow in terms of conflict resolution?
• Does your relationship reflect a shared ability to compromise? Is one partner compromising more than the other?
• Where/when do you struggle to work well together as a team?
• How do you tackle new problems that come your way as a couple?
• Do you have relationships with other people that create conflict with your partner, and if so, why?
• What do you do when you are angry with them?
• What does your partner do when angry with you?
• Are you able to have healthy versus unhealthy expressions of anger or do you struggle with emotion regulation or anger?
• What strengths and weaknesses do you have in resolving conflict?
• What would you say are your partner’s strengths and weaknesses in resolving conflict?
• Do you have difficulty setting and/or respecting other people's boundaries? 
• How do you repair ruptures in your relationship (“make up”)?