Brief Individual Relationship History

Date

First Name *

Last Name *

Email Address *

My clinician is: *Dr. Mark ZuccoloDr. Sonia MaxwellI don't know

If this is not your first marriage, indicate dates for each prior marriage (e.g., Marriage #1: married in 1995, separated in 2000, legally divorced in 2002; same for Marriage #2, etc.). Unmarried couples: skip to the next question.

Were you ever engaged to someone else and did not marry? When? Why did it end?

Prior to the current relationship, did you cohabit with a romantic partner? When? Why did it end?

In general, how often do you think that things between you and your Partner are going well?

Enter a number between 1 and 5 *1=Never - 5=All the time

Do you and your Partner still talk as friends, confide in one another, ask each other for advice?

Enter a number between 1 and 5 *1=Never - 5=All the time

How often do the following topics come up in the relationship: divorce, separation, breaking up?

Enter a number between 1 and 5 *1=Never - 5=All the time

When did the following topics first come up in the relationship: divorce, separation, breaking up?

Ex. January of this year, March of 2021, Never

If it is occurring, has this kind of talk become more frequent in recent times?YesNo

If it is occurring, who is more likely to bring it up—you or your Partner?I am more likely to bring it upMy Partner is more likely to bring it up

What best describes the degree of your happiness in the relationship?

Comments

In couples counseling, it is not uncommon for Partners to lean in different directions about whether to stay together or end the relationship. Enter the number that best describes your own “leaning” at this moment (5 = I'm not sure).

Enter a number between 1 and 10 *1=Definitely preserve the relationship - 10=Definitely end the relationship

What is your best guess for how your Partner is leaning? (5 = I'm not sure).

Enter a number between 1 and 10 *1=My Partner definitely wants to preserve the relationship - 10=My Partner definitely wants to end the relationship

Brief Individual Relationship History

Consider these items and check all that apply to how you currently feel. I am troubled by these issues in the relationship: *

Bellagio Psychotherapeutics

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Dr. Sonia Maxwell, PsyD, LMFT