Client Consent Form

Peter Fox Couple TherapistBSc MSc MICEEFT

Private & Confidential

Couple Intake Questionnaire

Last updated 20/10/2015

Ph.02 6684 0469 or SMS:0412 621 957 Post: PO Box 23 Mullumbimby NSW 2482

Web: Email:

This questionnaire will save time in sessions. Please add enough information to help me understand your situation. Snail mail (safer) or email encrypted (quicker) to me well before our first session. It will take about five working days to reach my Post Office box. If you send by email please convert to pdf and password protect. Send the password via SMS.

Confidentiality

All personal information is confidential. I will not disclose any information about you or your family to any other agency or person without your permission unless:

a. Mandated by a Court – usually in the form of a subpoena from lawyers in civil or criminal jurisdictions. The consequences are not insignificant - see:

b. You reveal a threat to the safety or integrity of yourself, someone in your family or to someone else.

c. Your prior approval has been obtained to communicate with another health care professional.

For service quality and supervision purposes I will sometimes discuss my treatment with my clinical supervisor, and I may record some clinical sessions. Any recording is treated as strictly confidential. Written permission will always be sought prior to the making and for the use of such recordings for any reason, including legal proceedings.

There are two columns for answers, one for each of you –that makes it easy for me to store securely, retrieve and read. The questions can stimulate discussion when completed together - unless of course honest answers provoke a fight.

Your answers will help me get up to speed with you both, and can send me a heads up of significant concerns prior to our first meeting and allows for an outcome measure of the effect of our work.

Personal details

Partner aPartner b

Family name
Given names
Preferred names
Yearand countryof birth
Number of dependents
Residential address
Postal address
Home & work phone
Mobile
Email
Occupation/s
Highest level of education

1a. Current relationship or marital status e.g. first marriage, step family, second marriage or if separated for how long? How long married/committed in this relationship?

Please list the names and year of birth of each of the children of this or previous relationships.

1b. In your first year as a committed couple did you experience a short (weeks) or long (months) honeymoon effect?Did youfaceany significant challengesin that first year? Please give brief details.

1c. What supports you in this relationship and brings out the best in you.

1d. Is your partner a close friend? Do you have a strong network of meaningful relationships and/or at least one other close friend?

1e. Have you a good enough safety history with each other - most always been there for each other in crisis, for example, with a miscarriage, loss of employment, life threatening accident or illness? Or are there particular events where one or other could not provide that safe harbour and it remains an issue, which comes back to bite you? If so, please give brief indication.

1f. Please choose a score from 5 meaning almost always the case to 1 almost never the case. If you are living apart or separated then describe the current situation as best you can[1].

From your viewpoint, is your partner accessible to you?
a. I can get my partner's attention easily. 5 4 3 2 1
b. My partner is easy to connect with emotionally. 5 4 3 2 1
c. My partner shows me I come first with him/her. 5 4 3 2 1
d. I am feeling lonely or shut out in this relationship. 5 4 3 2 1
e. I can share my deepest feelings with my partner. He/she will listen. 5 4 3 2 1
From your viewpoint, is your partner responsive to you?
a. If I need connection and comfort, he/she will be there for me. 5 4 3 2 1
b. My partner responds to signals that I need him/her to come close. 5 4 3 2 1
c. I find I can lean on my partner when I am anxious or unsure. 5 4 3 2 1
d. Even when we fight or disagree, I know that I am important to my partner and we will find a way to come together. 5 4 3 2 1
e. If I need reassurance about how important I am to my partner, I can get it. 5 4 3 2 1
Are you positively emotionally engaged with each other?
a. I feel very comfortable being close to, trusting my partner. 5 4 3 2 1
b. I can confide in my partner about almost anything. 5 4 3 2 1
c. I feel confident, even when we are apart, that we are connected to each other. 5 4 3 2 1
d. I know that my partner cares about my joys, hurts, and fears. 5 4 3 2 1
e. I feel safe enough to take emotional risks with my partner. 5 4 3 2 1 / From your viewpoint, is your partner accessible to you?
a. I can get my partner's attention easily. 5 4 3 2 1
b. My partner is easy to connect with emotionally. 5 4 3 2 1
c. My partner shows me I come first with him/her. 5 4 3 2 1
d. I am feeling lonely or shut out in this relationship. 5 4 3 2 1
e. I can share my deepest feelings with my partner. He/she will listen. 5 4 3 2 1
From your viewpoint, is your partner responsive to you?
a. If I need connection and comfort, he/she will be there for me. 5 4 3 2 1
b. My partner responds to signals that I need him/her to come close. 5 4 3 2 1
c. I find I can lean on my partner when I am anxious or unsure. 5 4 3 2 1
d. Even when we fight or disagree, I know that I am important to my partner and we will find a way to come together. 5 4 3 2 1
e. If I need reassurance about how important I am to my partner, I can get it. 5 4 3 2 1
Are you positively emotionally engaged with each other?
a. I feel very comfortable being close to, trusting my partner. 5 4 3 2 1
b. I can confide in my partner about almost anything. 5 4 3 2 1
c. I feel confident, even when we are apart, that we are connected to each other. 5 4 3 2 1
d. I know that my partner cares about my joys, hurts, and fears. 5 4 3 2 1
e. I feel safe enough to take emotional risks with my partner. 5 4 3 2 1

1g.Areyouliving fully by your values in the following four areas of life?Values are like a compass at the core of how you want to be in the world. A value of being loving is different from a goal of being married. This asks you about values not goals. Score: 5 = acting very consistently with my core values, to 1 = acting very inconsistently with my values, my actions are often in conflict with what I stand for.

Work/education 5 4 3 2 1
Personal growth/health 5 4 3 2 1
Relationships 5 4 3 2 1
Leisure 5 4 3 2 1 / Work/education 5 4 3 2 1
Personal growth/health 5 4 3 2 1
Relationships 5 4 3 2 1
Leisure 5 4 3 2 1

A free Life Values Questionnaire is on this page:

1h. From your point of view, do you score your partner differently than they have themselves, on the basis of the values you understand they hold dear in any of those areas? If so, which areas and what score.

1i. If you can, pleasechoose one of the following three attachment styles that best describes you most of the time in most close relationships or if not, go straight to the 36 item questionnaire linked below.

A. I am somewhat uncomfortable being close to others; I find it difficult to trust them completely, difficult to allow myself to depend on them. I am nervous when anyone gets too close, and often, others want me to be more intimate than I feel comfortable being.

B. I find it relatively easy to get close to others and am comfortable depending on them and having them depend on me. I don't worry about being abandoned or about someone getting too close to me.

C. I find that others are reluctant to get as close as I would like. I often worry that my partner doesn't really love me or won't want to stay with me. I want to get very close to my partner, and this sometimes scares people away.

D. I find I am often inconsistent and can contradict myself in my close relationship. I can reverse what I think and say I want and need in relationships, simultaneously or subsequently in how I act.

It is not always possible to choose one of these.

For an accurate readingcomplete the 36 item questionnaire here: about 5 minutes.

Please either copy and paste the conclusion of the quiz here:

2a. Were you adopted or fostered or had significant or lengthy separations from parents or care givers(including boarding school or hospitalisations),or lacked a consistent caregiver whowas in synch with you, who really understood you and your needs during childhood?

2b. What number were you of how many siblings (your birth order)? Are any of your siblings deceased or have suffered from chronic debilitating or life threatening illness or behaviour disorder? If so please give key words, duration and timing.

2c. Were you exposed to violence (physical, psychological, sexual) as a child from direct impact or witnessed? Was it alcohol/drug related? If so please give key words (e.g. parent, sibling, relative, paedophile) and approximate duration and timing.

2d. Are you currently in or near a work or home relationship that could be characterised as bullying, abusive or violating human rights, impacting you either directly or vicariously?

3a. Are there significant othersorcurrent third parties(other than children listed at 1a) who may be affected by our workor whose presence is a source of conflict, including former marital, extra-marital or extended family relationships. Their initials will do.

3b. Are their any health conditionsthat may be part of our work together for example chronic pain or ill health; digestive, respiratory and/or cardio vascular conditions; IVF program aftermath; bereavement; trauma,anxiety or depression; major accident or injury or disaster recovery?

3c. Are their any other social or employment conditionsthat may affect our work together?

4a.Do you have a good sleep at least 5 days a week and wake up feeling refreshed? If not please give some details about the disturbed sleep pattern, including if you are a mouth breather and/or suffer sleep apnea.

4b. How many hours a week do you work including house keeping, children’s activities coordinator, transport officer etc? Do you have adequate time out, rest and recreation for yourself as well as special couple times?

4c. Is it possible that you or your partner might be somewhat depressed or anxious? Please fill out these on line depression andanxiety screening surveys, and place your score in the box below. All the surveys are at an HON Certified site. I am confident of its privacy and code of conduct.

Consider these other brief screeningsurveysthat mayapply to either of you:

Sex addiction(max score possible = 16)
Emotional abuse at home(max score = 30)
ADD(max score = 120)
Bi-polar disorder(max score = 60)
Work place bullying(max score = 64)

Please note the results are only indicators they are not definitive, nor conclusive. I will follow them up in detail in our first session in order to clarify a survey indicator if appropriate.

Depression (max score 90) =
Anxiety (max score 66) =
Other quiz name/sresult/s = / Depression (max score 90) =
Anxiety (max score 66) =
Other quiz name/s & result/s =

Have you ever sincerely considered that you or your partner (or a parent or caregiver) may have or (have had) asevere personality or character disorder? For example, showing an unbalanced self-absorption withoutreal empathyfor its impact upon others (NPD) or catastrophic responses to rejection/abandonment and emotional storms out of left-field (BPD) or pre-occupied with order and control at the expense of openness and flexibility with a stilted expression of emotion (OCPD).

Explore the possibilities with anarcissism screen aborderline screen or anOCPD screen.

Result for who: / Result for who:

4d. Brief trauma screening – write or type yes or no (Y/N) in each of the following questions:

Whilst remembering horrendous personal events does your heart rate remain relatively stable?
Do you avoid reminders of an experience by staying away from places, people or activities?
Have you lost interest in activities that were once important or enjoyable?
Have you begun to feel more distant or isolated from other people?
Do you find it hard to feel love or affection for other people?
Have you begun to feel that there is no point in planning for the future?
Have you had more trouble than usual falling or staying asleep?
Do you become jumpy or easily startled by ordinary noise or movements?
Are small failures of communication difficult to gloss over and easily turn into catastrophic interpersonal conflicts? / Whilst remembering horrendous personal events does your heart rate remain relatively stable?
Do you avoid reminders of an experience by staying away from places, people or activities?
Have you lost interest in activities that were once important or enjoyable?
Have you begun to feel more distant or isolated from other people?
Do you find it hard to feel love or affection for other people?
Have you begun to feel that there is no point in planning for the future?
Have you had more trouble than usual falling or staying asleep?
Do you become jumpy or easily startled by ordinary noise or movements?
Are small failures of communication difficult to gloss over and easily turn into catastrophic interpersonal conflicts?

5a. What brought you to the decision to seek my assistance? Did someone refer you to me?Please give brief details.

As far as you know is any other member of your family or close friendship circle a current or past client of mine?

5b. ‘Buyer beware’: have you explored my website: It is your due diligence.

5c. Have you previously sought the care of a psychiatrist, psychologist or any other professional for relationship or health concerns of you or your significant others that are likely to come up in our work? (If yes, please indicate year with key words.)

6a. What outcomes from couple’s therapy are you hoping for?

6b. Have you considered the potential impact of couple’s therapy both for good and ill upon you and those near you and the impact upon your personal and professional life? Please read the risks at Item 9. below and advise me if any of these might apply to your current or projected situation?

6c. Are there any important specific events or issues, which you can think of that may be adversely impacted if one or more of the potential risks of the couple’s therapy process eventuates (eg a job interview, elective surgery, overseas posting/deployment or project deadlines).

6d. An Emotion Focused Couple’s Therapy is not for everyone. Have you any questions or concerns about:

Whether you should proceed with couple’s therapy at this stage or at all?
The proposed assessment and therapeutic processes used by me, and the likely impact both on you and on those around you who may be affected?
Fees payable and the likely time commitment involved?
My background qualifications and experience?
Other therapeutic options that may be available including for example self-managed behaviour change or alternative dispute resolution?
Do you have any other questions about any matter related to our work together?

6e. Is there anything else that might be important for me to know?This is the section to give me a heads up that there is something you’ve not fully shared with your partner. Some experience of yours that would be of material or psychological significance to them if they knew.

Thank you so much for your diligence in completing these exhaustive and at time challenging questions. I look forward to meeting you both. Peter.

8. Acceptance and consent

I have read this form carefully and have considered the potential risks, which may arise from emotion focussed couple’s therapy, and, being fully aware of those risks, and the potential impact upon my personal and professional life I choose to begincouple’s therapy subject to review.

Yes/no / Yes/no

To the best of my knowledge, I have indicated all factors in the items above, which may be relevant to the risk, appropriateness, timing and effectiveness of couple’s therapy including information, which is relationally significant to my partner particularly matters that impact upon trust in the relationship.

Yes/no / Yes/no

If anything about your situation or circumstances change in a way that will impact, on the potential risks of couple’s therapy or its effectiveness, please immediately inform me. Likewise, please raise with me any concerns or questions, which may come up during the process.

Cancellation policy: If you are late or do not arrive for a session, you are still financially responsible for the time we have scheduled. In order to cancel a session without charge, please give me 48 hours notice.

Fees: All fees are due at the time of session, unless we make alternative arrangements.

Electronic signature of the client (type your name) ______

Today's Date: ______

9. The risks of emotion focussed couple therapy

While people seek and derive many positive benefits from an emotion focussed couple therapy there are also risks. These arise from the effectiveness of the process as well as from a less than adequate fit of the process with the particular person.