Booking
About your relationship.
This helps us understand your relationship, your concerns and your hopes for your sessions.
Please answer as fully and honestly as you can. Everything here is confidential.
Your details
Mobile number (optional)
Your relationship
You are…
Please choose…
Dating Engaged Married
Civil Partnership Living Together Separated Other
Do you have children?
Yes No
If yes, please give ages (optional)
Have either of you been married or in a long-term committed relationship before?
Yes No
If yes, brief details (optional)
Have you attended relationship counselling or couples therapy before?
Yes No
If yes, brief details (optional)
What brings you here
What has brought you to relationship therapy at this time?
The main challenges you would like support with (tick any)
Communication
Conflict
Trust
Emotional Connection
Intimacy
Parenting
Life Transitions
Affair Recovery
Blended Family Challenges
Other
Further details (optional)
Your relationship strengths
What do you value most about your relationship?
What are your partner’s greatest strengths?
What is currently working well?
Communication & conflict
When disagreements occur, how do you typically respond?
How would you describe communication in your relationship?
Are there recurring conflicts or patterns that appear repeatedly?
Yes No
If yes, please describe (optional)
When conflict occurs, do you generally… (tick any)
Pursue discussion
Withdraw
Become defensive
Become critical
Avoid conflict
Other
Previous support & personal growth
Have either of you participated in… (tick any)
Individual Counselling
Psychotherapy
Coaching
Relationship Education
Imago Workshops
BWRT®
Other
Details (optional)
Safety & wellbeing
Please answer honestly. If you are experiencing abuse, threats or fear for
your safety, couples work may not be safe or appropriate right now. In an emergency call 999. For confidential
support, the National Domestic Abuse Helpline is 0808 2000 247 (free, 24/7).
Do either of you currently feel unsafe within the relationship?
Yes No
Has there been any history of… (tick any that apply)
Physical Violence
Emotional Abuse
Coercive Control
Threatening Behaviour
Substance Misuse
Serious Financial Secrecy
Other Safety Concerns
If yes to any, please give details (optional, confidential)
Are either of you currently experiencing significant mental-health difficulties that may affect participation?
Yes No
If yes, please give details (optional)
Your goals
What would you like to achieve through Imago Relationship Therapy?
What would success look like for your relationship?
Relationship snapshot
Rate each area as it is today, from 1 (very dissatisfied) through 5 (neutral / mixed) to 10 (very satisfied).
Communication
Emotional connection
Trust
Conflict resolution
Intimacy and affection
Feeling heard and understood
Friendship and enjoyment
Shared vision for the future
Overall relationship satisfaction
What is currently the strongest area of your relationship?
What area would you most like to improve through therapy?
Please complete the highlighted fields above.
Please complete the highlighted fields above.