Intake Questionnaire

About One Couple Intensive Session

The One Couple Intensive Session is a private, 3-hour virtual session with both Dr. Clint and Angelica, working with just your couple, one on one. Held over video, this session gives you focused, undivided time with both of us to work through what's actually going on in your relationship.

Unlike the group workshop, this session is built entirely around you and your partner. Clint and Angelica work directly with your specific situation, helping you understand the patterns driving conflict or disconnection, and giving you real strategies to work with immediately.

This is the format to choose if you want depth and privacy without committing to a full weekend retreat.

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One Couple Intensive Session

Thank you for your interest in A Friendly Shoulder One Couple Intensive Session. This questionnaire helps us understand your relationship, your goals, and any safety or health needs, so we can create the safest and most supportive experience possible. Please answer honestly and in as much detail as you feel comfortable. Both partners should review the questions together. For certain questions, each partner can respond separately.

Full name. Partner A

DOB mm/dd/yyyy. Partner A

Phone

Full name. Partner B

DOB mm/dd/yyyy. Partner B

Phone

Address

How did you hear about us? (friend, social media, therapist, etc.):

Are you married/engaged/dating/living together/separated but working on reconnection/other?

What made you decide to reach out and consider this retreat now, at this point in your relationship?

What are your top 3 goals for this retreat as a couple?

On a scale of 1 to 10, how committed are you to working on this relationship right now? Partner A

On a scale of 1–10, how committed are you to working on this relationship right now? Partner B

What are the main challenges or repeating conflicts in your relationship right now?

If you had to name one ‘core theme’ of your struggles (for example: trust, communication, emotional distance, conflict style, past betrayal, intimacy, parenting, money, etc.), what would it be?

How do conflicts usually look between you? (quiet distance, explosive arguments, shutting down, walking away, etc.)

Is there any history of: emotional abuse, physical aggression, threatening behavior, or feeling unsafe in this relationship? If yes, please describe what feels important for us to know.

Is there any current legal situation, restraining order, or active court case involving either partner that we should be aware of?

Have either of you ever worked with a therapist, coach, or counselor (individually or as a couple) before? If yes, what helped and what did not help?

Have either of you ever been diagnosed with a mental health condition (for example: depression, anxiety, bipolar, PTSD, etc.)? If yes, please describe only what you’re comfortable sharing and whether you are currently receiving support.

Are either of you currently taking any psychiatric medication? If yes, please list the medication names (if you feel comfortable) and whether everything is currently stable.

Are there any topics that feel especially sensitive or potentially triggering for you (for example: past trauma, violence, infidelity, addiction, grief, family issues)?

Is there any current or past struggle with addiction (alcohol, drugs, gambling, etc.) that you feel is important for us to know about?

Do you have any financial concerns about attending (payment plans, deposits, etc.) that you’d like us to know about so we can discuss options?

Is there anything else you would like us to know about you, your partner, or your relationship before we confirm your spot?

Please share with us a photo of two of you (For internal use only. It will never be shared with anyone or anywhere.)

Thank you for taking the time to fill this out. Everything you share is treated with respect and confidentiality within the limits of safety and the law. Once we receive your questionnaire, we will review it and contact you with the next steps.

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