Michael DiPaolo, Ph.D.

Name
First Last
Date
MM slash DD slash YYYY
E-Mail Address
Partner Name
Length of Relationship
Do you have any children?
- Yes
- No
Please give names and ages
The remainder of items on this first page asks for information about you. The second and third pages ask about your relationship.
Occupation
Religion/Spirituality
Do you have any current or past medical conditions?
- Yes
- No
Please describe
Do you have any current or past mental health issues (including anxiety, depession, etc.)?
- Yes
- No
Please describe
Do you have any addictions?
- Yes
- No
Please describe
Are you taking any medications?
- Yes
- No
Please describe

The following is a list of areas which can bring couples closer together or lead to disagreements or dissatisfaction. Please fill in the bubble which represents your level of satisfaction in each area.

	Very Dissatisfied	Dissatisfied	Neutral	Satisfied	Very Satisfied
Your friendship
Quality time together
Demonstrations of affection
Sexual relationship
Trust or jealousy
Communication
Moodiness/temper/emotionality
Aims, goals, priorities, major life decisions
Managing the home/chores
Career decisions or work
Work-Life Balance
Finances
Children or parenting
Extended family (in-laws/relatives)
Religion/Spirituality
Social behavior or appearance
Use of technology (cell phone, TV, computer, video games, etc.)
Alcohol or drugs
Pornography
Other Addictive Behavior

Other
Overall satisfaction with your relationship
Very Dissatisfied Dissatisfied Neutral Satisfied Very Satisfied
I am committed to our relationship.
10987654321
I am committed to doing all I can, including this couple therapy, to address our current issue.
10987654321

What will your relationship look like if our work together is wildly successful?
What are you (not your partner) doing now that keeps you from having the relationship that you long for?
What could you (not your partner) do differently that would help you create that relationship?
Please describe a recent interaction between you and your partner that is typical of the positive features of your relationship.
Are there any additional comments that you would like to make?
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Clinical Psychologist