Couples Form

I/We understand and consent to the above counselling and service conditions.

Client Name(s)

Signature – consent provided

Demographic Information

First Name

Last Name

Date of Birth

You are registering for a couples session. Please enter your partner's information:

Partner's First Name

Partner's Last Name

Partner's Date of Birth

Please continue entering your information:

Your Gender Identity

Preferred Pronouns

E-mail

Do we have your permission to send you an e-mail?YesNo

Home Phone

Work Phone

Cell Phone

Can we leave a message at the phone numbers listed?YesNo

Address

City

Postal Code

Emergency Contact

Languages spoken at home

Who else lives in your household? (such as children, dependents, roommates, or other family members)

First Name

Last Name

Date of Birth

Relationship

First Name

Last Name

Date of Birth

Relationship

First Name

Last Name

Date of Birth

Relationship

Have you been to walk-in Counselling Clinic before?YesNo

Do you have an EAP (Employee Assistance Program) through your employer?YesNo

Employer:

What would you like to talk to a counsellor about today?

Risk Assessment Summary

Have you ever been affected by any of the following?Addictions (alcohol, drugs, gambling)Intimate partner or family violenceSexual assaultDevelopmental disabilitiesFinancial problemsWork or interpersonal conflictRisk to self or other

Intimate Justice Scale

Please rate each statement on a scale of 1 to 5 (1 means “I do not agree at all” and 5 means “I strongly agree”).
Your answers are confidential and will not be shared with your partner.

My partner never admits when she or he is wrong.

My partner is unwilling to adapt to my needs and expectations.

My partner is more insensitive than caring.

I am often forced to sacrifice my own needs to meet my partner’s needs.

My partner refuses to talk about problems that make him or her look bad.

My partner withholds affection unless it would benefit her or him.

It is hard to disagree with my partner because she or he gets angry.

My partner resents being questioned about the way he or she treats me.

My partner builds himself or herself up by putting me down.

My partner retaliates when I disagree with him or her.

My partner is always trying to change me.

My partner believes he or she has the right to force me to do things.

My partner is too possessive or jealous.

My partner tries to isolate me from family and friends.

Sometimes my partner physically hurts me.