Couples/Family Intake Assessment (Relationship History)

Date of Service: [Date]

Location/Setting: [Clinic / Office / Home / Other]

Modality: [In-person / Telehealth video / Telehealth audio-only]

Provider: [Name, credentials]

Participants

(List all persons present with role, names, relationship role, and pronouns if provided. Note interpreter use and consent status for non-clients if applicable.)

• Partner A: [Name], [relationship role], [pronouns]
• Partner B: [Name], [relationship role], [pronouns]
• Others present: [Name, role, consent status] (Only include if applicable)

Identified Patient and Client Unit

Identified Patient (Patient of Record): [Name]

Relationship of Other Attendees to IP: [partner / spouse / parent / child / other]

Clinical Rationale for Conjoint Format: [1–2 sentences explaining how partner/family involvement supports treatment of the IP's condition and functioning]

Record Model: [Single joint record / Separate individual records] — [Brief note on access/release rules discussed with clients]

Informed Consent and Confidentiality

(Briefly document informed consent topics reviewed. Note any client questions or exceptions.)

• Nature of conjoint treatment and limits of confidentiality: [Reviewed / Not reviewed today / Client declined] — [Notes]
• How records are maintained and who may access them: [Reviewed / Not reviewed today / Client declined] — [Notes]
• Release-of-information expectations with multiple clients: [Reviewed / Not reviewed today / Client declined] — [Notes]
• Safety-related limits (duty to warn, abuse reporting): [Reviewed / Not reviewed today / Client declined] — [Notes]
• Communication channel preferences and boundaries: [Reviewed / Not reviewed today / Client declined] — [Notes]
• Client questions or exceptions: [Summary]

Presenting Concerns

Reason for Visit: [Referral source, primary concerns prompting intake, precipitating factors] (2–4 sentences focusing on why now)

Partner Goals:

• Partner A goals: [1–3 items]
• Partner B goals: [1–3 items]
• Shared goals: [1–3 items]

Functional Impact on Identified Patient: [Brief description of how relationship distress affects IP's functioning: sleep, work, mood, parenting, social engagement, etc.]

Relationship History

(Document a concise timeline with key anchor points. Use one line per event with approximate dates and perceived impact.)

• [Date/Range] — [How/when they met]
• [Date/Range] — [Commitment milestones: cohabitation, marriage, children]
• [Date/Range] — [Major ruptures or repairs: separations, betrayals, reconciliations]
• [Date/Range] — [Significant external stressors: job loss, illness, moves, grief]
• [Date/Range] — [Prior couples/family therapy and outcomes]

Relationship Strengths and Protective Factors: [What works well, prior successful repairs, shared values, teamwork]

Current Relationship Functioning

(Summarize current functioning across relevant domains. Note living situation, separation discussions, and children/custody if relevant. Mark domains not assessed as such.)

• Communication and emotional attunement: [Summary / Not assessed]
• Conflict management and problem-solving: [Summary / Not assessed]
• Household roles and responsibilities: [Summary / Not assessed]
• Parenting and co-parenting: [Summary / N/A / Not assessed]
• Emotional and physical intimacy: [Summary / Not assessed]
• Finances and decision-making: [Summary / Not assessed]
• Extended family boundaries: [Summary / Not assessed]
• Substance use effects on relationship: [Summary / Denied / Not assessed]
• Mental or medical health stressors: [Summary / Not assessed]
• Current living situation: [Together / Apart] — [Separation discussions if any]
• Children in home: [Names/ages or count, custody arrangement] (If applicable)

Conflict Cycle and Communication Patterns

Typical Triggers: [List 3–5 common conflict triggers by theme or context]

Conflict Cycle: [Trigger] → [Partner A perception and response] → [Partner B perception and response] → [Escalation or withdrawal pattern] → [Repair attempts if any] → [Typical aftermath] (Use neutral, non-blaming language)

Communication Pattern: [Predominant pattern: pursue-withdraw / mutual escalation / criticism-defensiveness / stonewalling / other] — [What de-escalates] — [What blocks repair]

In-Session Observations: [Behavioral observations: tone, interruptions, emotional regulation, capacity for reflection and empathy, alliance dynamics, concerning interactions] (Distinguish observed behaviors from reported content)

Safety Screening

(This section must be completed explicitly. Never leave blank. If risk is present, document level, immediate actions, and safety plan.)

Suicide/Homicide Risk (Identified Patient):

• Status: [Screened - Negative / Screened - Positive / Not assessed today (reason) / Client declined]
• Screening method: [Tool per protocol or clinical interview]
• Findings: [Current ideation, plan, intent, past attempts, access to lethal means, protective factors] (Include only if clinically indicated)
• Risk level: [Low / Moderate / High] — [Rationale] (If applicable)
• Immediate actions: [Means restriction counseling / Safety planning / Crisis line offered / Emergency services / Collateral contacted] (If risk present)

Intimate Partner Violence Screening:

• Status: [Screened - Negative / Screened - Positive / Not assessed today (reason) / Client declined]
• Screening method: [Individual with each partner / Joint] — [Rationale if joint]
• Findings: [Summary using minimal necessary detail]
• Safety steps: [Resources provided, safety planning, rationale for conjoint appropriateness] (If concerns present)

Child Safety: (If children or vulnerable persons involved)

• Status: [Screened - Negative / Screened - Positive / Not assessed today / N/A]
• Concerns: [Abuse, neglect, exposure to violence] — [Summary]
• Mandated report: [Filed / Not filed] — [Rationale]

Safety Plan: [Crisis contacts, emergency instructions, follow-up plan, client understanding] (If any risk identified; otherwise N/A)

Relevant Individual History

(Briefly summarize individual factors relevant to relationship functioning and safety. Defer comprehensive individual assessments as needed.)

Identified Patient:

• Mental health history and current symptoms affecting relationship: [Summary / Not assessed]
• Trauma history affecting attachment, trust, or conflict patterns: [Functional impact / Not assessed]
• Substance use: [Summary / Denied / Not assessed]
• Significant medical factors: [Summary / Not assessed]
• Current treatments and medications: [Summary / Not assessed]

Partner B:

• Mental health history and current symptoms affecting relationship: [Summary / Not assessed]
• Trauma history affecting attachment, trust, or conflict patterns: [Functional impact / Not assessed]
• Substance use: [Summary / Denied / Not assessed]
• Significant medical factors: [Summary / Not assessed]
• Current treatments and medications: [Summary / Not assessed]

Mental Status Observations

(Focused MSE for the Identified Patient. Distinguish observed behavior from client-reported experiences. Include partner observations only if clinically relevant.)

• Appearance and behavior: [Observed description]
• Speech: [Rate, volume, fluency]
• Mood (reported): [Client's stated mood]
• Affect (observed): [Range, congruence, reactivity]
• Thought process and content: [Coherent / Linear / Rumination / Other]
• Perception: [Hallucinations / Illusions / Denied / Not assessed]
• Cognition and orientation: [A&O status, attention, memory] (If indicated)
• Insight and judgment: [Description]
• Risk-relevant findings: [Behaviors or statements indicating risk]
• Partner observations: [Brief, clinically relevant findings] (If applicable)

Assessment and Formulation

Clinical Formulation: [One integrative paragraph synthesizing key relationship patterns, current conflict cycle and maintaining factors, and protective factors/strengths]

Diagnostic Impression (Identified Patient):

• Primary diagnosis: [Diagnosis name] (ICD-10: [Code])
• Secondary diagnosis: [Diagnosis name] (ICD-10: [Code]) (If applicable)
• Relational problem codes: [Code name] (ICD-10: [Code]) (If applicable)
• Differential diagnoses or rule-outs: [Brief list with rationale] (If indicated)

Medical Necessity: [1–2 sentences connecting IP symptoms and impairment to need for skilled conjoint intervention] (If insurance-billed)

Plan of Care

Treatment Approach: [Conjoint couple therapy / Family therapy / Combination with individual sessions] — [Frequency] — [Anticipated duration]

Goals: (2–4 measurable goals tied to conflict cycle and stated priorities; identify early-stage targets)

• [Goal 1 with measurable criteria]
• [Goal 2 with measurable criteria]
• [Goal 3 with measurable criteria] (If applicable)
• [Goal 4 with measurable criteria] (If applicable)

Referrals: [Individual therapy / Psychiatry / IPV resources / Parenting support / Child therapy / None indicated]

Follow-Up: [Next appointment date/time] — [Contingency plan if risk escalates]

Session Documentation

Session Duration: [Start and stop time or total minutes]

Interventions: [Techniques used: assessment interviewing, cycle mapping, psychoeducation, de-escalation coaching, safety planning, resource linkage, goal-setting]

Clinician Signature: [Name, credentials, date/time]