Couples Questionnaire

Thank you for booking. Please complete this ahead of our first session — it helps me understand your experience of the relationship so we can make the best use of our time together. There are no right or wrong answers; what matters is your honest experience.

Each partner completes a separate copy. Please answer individually, without discussing your responses with your partner beforehand.

About You & the Relationship

Your name *

Partner's name *

Your email *

Length of relationship

Relationship status * Select all that apply

Married

Separated

Divorced

Dating

Living together

Living apart

Do you have children together, or children who are part of the household?

Yes

How many, and their ages?

How Things Are Now

How would you rate your happiness in the relationship? *

Your current level of stress (overall)?

Your current level of stress (in the relationship)?

Has either of you threatened to separate or end the relationship?

Yes

Who, and what happened?

Do you feel that either of you has withdrawn from the relationship?

Yes

Who?

Partner

Both of us

How enjoyable is your sexual relationship? Leave blank if you'd prefer to discuss this in session

How satisfied are you with the frequency of sexual relations?

Safety & Background

Has either of you struck, physically restrained, used violence against, or physically injured the other? *

Yes

Please briefly describe — who, how often, and what happened

Does either of you drink alcohol or use drugs to the point of intoxication?

Yes

Who, how often, and which substances?

Have you received a psychiatric diagnosis?

Yes

Prefer to discuss

Diagnosis and any current medication

Previous Counselling

Have you received couples counselling before?

Yes

What was the outcome?

Has either of you been in individual counselling?

Yes

Brief summary of what was addressed

Relationship Timeline

Draw a line showing your relationship satisfaction over time Click or drag to draw. Mark significant events — births, losses, moves, affairs, separations. This doesn't need to be precise; it's about the shape of your experience.

Satisfied Unsatisfied

When you met Today

Click and drag to draw your satisfaction line

One Last Thing

Is there anything you'd like me to know that you're not sure how to say in front of your partner? This is optional. Please be aware that I work with a no-secrets policy in couples counselling — I won't keep information from one partner hidden from the other. If you share something here, I may gently encourage you to bring it into our shared work when the time feels right.

This will open your email app with your responses ready to send.
Your information goes directly to me — it is not stored or processed by any third party.

Your data is handled in accordance with UK GDPR. It is sent directly from your email to mine and is not stored on this website or processed by any third-party service. See my privacy policy for full details.

Thank you

Your email app should have opened with your questionnaire ready to send. Once sent, I'll review your responses ahead of our first session.

If your email app didn't open, you can copy your questionnaire and paste it into an email to info@jacobpagecounselling.com

Copied - just paste it into an email to me.