History questionnaire couple

Welcome to the Couples Medical History Questionnaire

Please take the time to answer the following questions as best you can. Each person fills out a form individually. If there are any questions (other than address and contact details) that you do not want to answer, simply leave them out. The information will help us to optimally prepare the meetings and to understand your topic. Of course they will be treated completely confidentially.

Thank you in advance for your time and trust.

If we have any questions about your comments, we will ask them at the next meeting.

With kind regards, Anika Schwenker & Andreas Thome

Family name

Given name

Street name and number

Postal code

City

E-Mail

Phone number

Country

Date of birth

Gender

female

male

divers

Profession / workPlease write in the comment section your current profession / work position and in whatever applies to you.

Rather full time

Rather part time

At the moment out of work

Taking a sabbathical (or similar)

Still in training / university

What is your current profession / work position?

Do you currently experience mental health problems?

Please let us know about any diagnosis that you have received from a psychiatrist or other therapist?

Also any mental disorder that you might think you have (depression, anxiety, PTSD...).

No or not that I would know.

Yes, the following:

Are you currently in therapy?If yes, please write in the comments section for how long you have been in therapy and what kind of therapy you are having.

Yes, in a behavioural therapy

Yes, in an analytical therapy

Yes, in a systemic therapy

Yes, in the following kind of therapy

Do you take any psychotropic drugs?Please indicate any prescription or non-prescription drugs in the comments section.

Yes, the following:

Are there currently any significant physical illnesses?Please not in the comments section if any

Yes, the following:

Duration of the current partnershipPlease state the total duration since the year you met. If you are married, separated or divorced, please also state for how many years.
Example: "12 years old, married for 3 years, separated for 6 months"

Living situationDo you live together as a couple?

Living together

Living apart since:

Children with another

Please indicate the number, gender and age of your children together.
e.g.: Three children, female (9,13), male (15)

None

The following:

Former significant relationships / mariagesPlease briefly describe your own significant, multi-year relationships prior to your current relationship with approximate age information.
e.g.: partnership (22-28 years), marriage (29-42 years)

None

The following:

Children from previous relationshipsPlease indicate the number of your own children from previous relationships, if any. Their gender, age and whether they live in your household. e.g.: Two children from his first marriage, son (13), daughter (15), with us every other weekend

None

Yes, the following on my side and from my partner:

Desire to have children / miscarriages / abortionsPlease select everything that applies to your current relationship. If the desire to have children was or is one-sided, please use the comment field to explain which of you has or had the desire. e.g.: My wish

Unfulfilled mutual desire to have children

Unfulfilled one sided desire to have children

Miscarriages

Abortions

None of the above

Do you have experience with couples therapy or counseling?Please briefly explain what you have done in your previous or current relationship.

I have not done anything yet of that sort

I have already received the following therapies/advice:

Positive experiences couple therapy/counselingIf you have had any experience, what did you particularly like? Please use the comments section

I have no (positive) experience with couples therapy

I particularly liked:

Negative experiences couple therapy/counselingWhat did not you like? What would you have liked to have been different?

I have no (negative) experiences with couples therapy

I disliked the following:

What character traits do you particularly like or liked about your partner?Even though it may be difficult at the moment, remember the beginning of the relationship and write down 1-3 characteristics of your partner that you particularly liked then or still like. e.g.: "Creative, courageous and family-oriented" or "intelligent and loving" or "independent" etc.

What do you think your partner likes (liked) about you?Please briefly describe what you think. Name 1-3 of your qualities that you think your partner particularly likes or liked.

How satisfied are you currently with your sexuality as a couple?Please tick what applies to you personally

Totally satisfied

Rather satisfied but I also see room for growth and change here

Rather dissatisfied. This aspect of our relationship desperately needs attention

Other answer

What is your main concern for this couples therapy?Please briefly describe what led you to the decision to seek support for your partnership. What do you see as the main problem or challenge for your partnership? If you are not in a crisis, for example if you have grown apart or are primarily interested in maintaining relationships or certain aspects of the partnership (communication, sexuality, tenderness), you can also describe this here.

What do you think is the cause of the current crisis?Please briefly describe what trigger you suspect, if in your opinion there is one.

Are there times at the moment when you don't argue?

Please think about what resources you have available to you as a couple at the moment. Are there areas of life in which you agree?
Briefly describe when this happens and what is different then.
E.g.: "When it comes to the children, we always agree" or "When we are on vacation and can relax, we get along very well"

What would you consider a success for this therapy?Imagine that you have processed everything that was important to you. What would be different between the two of you? What would there be more of, what less of? Please refer as much as possible to the partnership and your own goals and not to what you would like to have different about your partner.
Example: "Successful therapy would bring us closer together again and create new trust. We would also communicate more and better with each other. I would finally have the courage to address my needs instead of expecting people to guess them."

How should we handle the bill?

If you fill out this form it probably means we will have our first (online) session soon. We will send you the invoice for this together with our account details by email after the appointment. Please then transfer the amount to be paid. In order to create the invoice correctly, please let us know who we should address it to.

The total amount in my name & address

Divide the amount by two and send both participants an invoice

The total amount in the name and address of my partner

Use the following name & address (and possibly distribution):

Are you already familiar with Zoom video conference calls??Since we might be holding our joint sessions via Zoom, we want to make sure that you have already installed the app and checked your video and audio. Then we don't lose valuable time on technical matters during the meeting. If you don't know your way around yet, we'll be happy to help.
We will send you the link for the session at least 15 minutes before the start of the session for the first session and it remains the same.

I'm already familiar with Zoom.

I don't know exactly how this works and I need help.

Other comments:

What made you choose us?Please select everything that applies.

Therapie mit Therapeutenpaar

Möglichkeit der Online-Therapie

Die Informationen auf der Webseite hat mich angesprochen

Das Video auf der Webseite hat mich angesprochen

Ich fand Sie beide sympathisch

Das Einführungsgespräch hat mich überzeugt

Empfehlung durch:

Do you accept our terms and conditions?AGB zusammen wach 3_2021

I have read and accepted the general terms and conditions

I do not accept the general terms and conditions and have the following proposed change:

Time is Up!