Healthcare Couples Intake Questionnaire

Healthcare Couples Intake Questionnaire

Please complete this intake questionnaire for both partners. The information collected will be used to assess clinical needs and plan couple or conjoint care. All responses are part of your confidential clinical record. If you have questions while completing this form, please discuss them with your clinician.

Intake Information

Partner 1 — Personal Information

Date of birth:    Gender:

Phone:    Email:

Partner 2 — Personal Information

Date of birth:    Gender:

Phone:    Email:

Insurance & Billing

Emergency Contact

Relationship:    Phone:

Relationship & Presenting Concerns

Medical & Mental Health History

Current medications — Partner 1

Allergies — Partner 1

Significant medical/psychiatric history — Partner 1

Current medications — Partner 2

Allergies — Partner 2

Significant medical/psychiatric history — Partner 2

Medical Conditions Checklist

Partner 1: Check conditions that apply

Partner 2: Check conditions that apply

Substance Use / Safety Screening

Have either of you ever experienced thoughts of harming yourself or others in the past year?

Domestic/Intimate Partner Violence

For safety and treatment planning, please indicate whether there has been physical violence, threats, or coercive control in this relationship within the past 12 months. Disclosure will be used to assess risk and provide appropriate referrals. Answers will be documented in the clinical record and may affect treatment planning.

Prior Treatment

Consent, Confidentiality & Authorization

By signing below, each partner acknowledges receipt of the practice's privacy notice and consents to participate in couples or conjoint clinical services. Couples therapy involves joint sessions in which content disclosed by one partner may be discussed with the other. Therapists cannot guarantee privacy between partners with respect to shared session material. If individual sessions are requested, the clinician will discuss limits of confidentiality and record-keeping; however, in some cases, the clinician may be unable to keep individual communications confidential if doing so would harm the therapeutic process or other legal/ethical obligations apply.

Exceptions to confidentiality include situations where there is a reasonable belief of imminent risk of harm to self or others, suspected child or dependent adult abuse, court order, or other legally required disclosures. Information necessary for treatment coordination, billing, or quality assurance may be shared with administrative staff, billing/insurance, and other treating providers only as required for care and payment.

I authorize the release of any information necessary to process insurance claims and authorize payment of benefits to the treating provider. This authorization expires on:

I consent to receiving appointment reminders and non-sensitive communications via phone or email as indicated above. I understand that electronic communications may not be completely secure and consent to use them for routine scheduling and administrative matters.

By checking the box below, each partner acknowledges understanding and acceptance of the above statements.

Authorization for Release of Information (Optional)

I authorize the practice to release clinical information to the persons or agencies listed below for the purposes indicated (e.g., coordination of care). This authorization may be revoked in writing at any time except to the extent that disclosures have already been made in reliance on this authorization.

Acknowledgment & Certification

Each partner certifies that the information provided on this form is true and complete to the best of their knowledge. Each partner understands that omissions or misrepresentations may affect clinical recommendations. Signing constitutes informed consent to evaluation and, where appropriate, couples or conjoint treatment under the terms described above.

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