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INTAKE

Please help me to help you by completing the intake information here. These forms are for assessment and preparation for our first session together. It will take you approximately 10 minutes to complete the two sections (background and mental health).

If you are coming to see me as a couple then please both fill out the the intake forms here. You can e-mail your partner a link to this intake form here. Please do this without consulting one another over questions regarding relationship quality or the perceived intensity of any mental health issues.

Okay, let’s get started:

EN - Intake Form (background information) - include contact data

Personal Details

Contact Information

Demographic informationen

Information zur Beziehung

Information about the deceased partner

Please enter the details (name and date of birth) of all your children below. Use the "plus" symbol on the right-hand side to add a child.

Marriage history

Perceived quality of your current relationship

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Further questions on relationship quality

The following sections relate to the quality of your relationship. Please answer questions on a scale of 0-4 where,

0 = Never true;
1 = Rarely true;
2 = Sometimes true;
3 = Usually true;
4 = Always true.

  

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

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

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0

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

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0

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

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0

The following questions are about how emotionally ENGAGED you are with your partner

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The following questions are about how emotionally ENGAGED your partner is with you

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0