The purpose of this document is to help us explore your current needs, your background, and your goals for therapy. By gathering this information before we agree to a session, we can build a clear picture of what you are experiencing and ensure that online psychotherapy is the right and safe space for you, and that I have the necessary expertise to help you achieve your specific couples' therapy goals.
What Happens to Your Completed Form:
All information provided in this form is strictly confidential. Your data is handled and securely stored in full compliance with UK Data Protection law (UK GDPR) and my registration with the Information Commissioner's Office (ICO). It will not be shared with anyone without your explicit consent, except under the rare legal and safeguarding limits outlined in our Individual Client Therapy Agreement. Should you choose not to start therapy with me, I will permanently and securely delete this form.
Section A: Administrative and Online Safety
Email Address *
Physical Address (Where you will be during online sessions)
Is Online Therapy Safe and Practical for You?
Section B: About You as an Individual
(This section helps understand individual backgrounds, personal mental health, and caregiver history)
What Is Going on For You Personally Right Now?
Do you have a formal diagnosis or suspect one? (e.g. ADHD, Autism, Bipolar, OCD, EUPD, etc.)
Are You Struggling Specifically with Anxiety, Depression, Addiction, or Suicidality?
Emergency & Crisis Disclaimer:
This private online practice does not provide an immediate emergency or crisis intervention service. If you feel unsafe, are in immediate danger of hurting yourself, or are experiencing a severe mental health crisis, please contact your local emergency services immediately by calling 999 or visiting your nearest Accident & Emergency (A&E) department. You can also call the NHS medical line on 111 , contact your local GP surgery, or call the Samaritans on 116 123 .
Do You Take Prescribed Psychotropic Medication?
Current Dosage & Frequency (if known):
What Were Your Childhood Caregiver Experiences?
What Were Your Prior Adult Relational Dynamics Like?
Do You Have any Prior Therapy Experience?
If YES, please briefly outline 1) Type of therapy, 2) When, 3) Duration, and 4) Primary focus:
What Do You Want from Me as Your Therapist?
Would you like to share anything else about yourself here?
Section C: About the Couple
What Is Your Story and Relational Journey?
When and where did you meet?
What first attracted you to your partner?
When did you decide you were in a committed relationship / how long together?
Have there been significant challenges or obstacles in the partnership? What were they?
How Would You Rate Your Partnership Satisfaction?
If you could change one thing about yourself in the relationship, what would it be?
If you could change one thing about your partner, what would it be?
What are you hoping for from couple's therapy? What are your hoped-for outcomes?
What Do You Consider to be the Core Relationship Focus Areas?
What Stressful Life Events and External Pressures Are in the Mix?
Other Outside Issues / Systemic pressures affecting your dynamic:
What Are the Current Conflict & Relational Reactivity Loops?
Are There Any Individual Safety & Safeguarding Concerns?
Next: Agreement & Informed Consent