TEMPLATE FOR THERAPISTS
Relationship Therapy Intake Questionnaire
Most relationship intake forms ask about presenting concerns and therapy history. That's a starting point—but it's not a picture of the people in the room. It doesn't ask what each person is actually carrying. What they've never been able to say out loud. What they wish the other person understood about their inner world. What they're afraid might be true.
This form does. And it asks each participant to answer alone—before the first joint session—so they can be honest before they have to be brave.
This is a comprehensive relationship therapy intake questionnaire completed individually by each participant before the first session. Because it's designed for a no-secrets practice, clients are told upfront that what they share may be brought into the work—which is what makes the answers worth having.
It covers eleven sections: the relationship structure and how each person would describe it right now, what brought them to therapy, their individual perspective on what's hard and what's worth protecting, their personal wellbeing and what they're carrying outside the relationship, goals and hopes, communication and conflict patterns, and a full section on connection and intimacy across seven dimensions—emotional, intellectual, physical affection, sexual and erotic, spiritual and meaning-based, recreational and playful, and practical and daily. Not because all of those will be the focus of therapy, but because knowing where people feel close and where they feel distant is some of the most useful clinical information there is.
It also includes a dedicated section on living situation and distance—including long-distance, military, and geographically separated relationships—a relationship structure and agreements section that asks about spoken and unspoken expectations, a culture and identity section that treats difference between participants as texture to understand rather than conflict to manage, and a safety screen that gives each person a private way to flag concerns before joint work begins.
It closes with a pre-session acknowledgment that names seven things people commonly feel walking into relationship therapy—including ambivalence about the relationship itself—because naming them before they happen reduces shame and keeps people in the room.
Every placeholder is marked in red. Teal clinician notes explain each section and flag decisions throughout. It's designed to be used after the Relationship Therapy No-Secrets Policy has been signed—not instead of it.You're starting relationship therapy with an intake process that doesn't actually tell you who's in the room—and especially if any of these sound familiar:
You want each participant's honest individual perspective before the first joint session—not a shared narrative that's already been edited
You work with relationship configurations beyond the two-person monogamous model and need your intake documents to reflect that without making anyone feel like an exception
You want to ask about intimacy across more than one dimension—because connection isn't only about sex, and distance isn't always physical
You work with long-distance, geographically separated, or military relationships and want questions that actually account for that context
You practice with a no-secrets framework and want your intake form to be honest about that from the first question
You want a safety screen built into the individual intake—so each person has a private way to flag concerns before joint work begins
You believe that how people describe their relationship on paper, alone, before anyone else can hear them, is some of the most honest data you'll ever get
1. Download and open—The template is a .docx file. Open it in Microsoft Word or Google Docs.
2. Replace the red brackets—Fill in your practice name, year, and any configuration-specific language before sharing with clients.
3. Review the teal notes—Throughout the document, teal clinician notes explain the purpose of each section and flag decisions to make—which sections to keep, adapt, or remove based on your client population. Delete all notes before finalizing.
4. Send it individually—Each participant completes their own copy, separately, before the first session. This is not a form to complete together.
5. Use it after the No-Secrets Policy is signed—This questionnaire is designed to be completed after all participants have reviewed and signed the Relationship Therapy No-Secrets Policy & Shared Commitment.
6. Remove the clinician instruction page—This must be removed before sending to clients.
7. Save as a PDF—When your edits are complete, save a final version as a PDF before sending to clients or uploading to your EHR.
8. Have it reviewed—Before distributing to clients, have your final version reviewed by your licensing board, malpractice carrier, and/or a licensed attorney. Requirements vary by state.
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