Relationship Advice

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About You...

Please take your time to complete the following questionnaire in as much detail as you possible can. The more information you're able to give to our therapists, the easier it is for us to understand your personal situation and give a detailed reply. If the question really isn't relevant to your situation in any way at all, please leave it blank and move on.

Name:

Gender:

Male Female

Please enter your email address so we can send you your individual consultation. Please enter it twice so we can make sure it's right:
Email:

Email:

Age:

18-25 26-30 31-40 41-50 51-60 61-70 70+

Sexual Orientation:

Please say how you would describe your ethnicity:

Relationship Status:

Single

Dating

Married/Cohabiting

Separated/Divorced

If you are in a relationship, is your partner aware that
you are seeking help for this problem?

Yes No

1. Are your currently suffering any physical or mental illness?

Yes No

If Yes, please specify:

2. Are your currently seeing a doctor/specialist for any physical or mental illness?

Yes No

If Yes, have you spoken to them about your problem?

Yes No

3. Are your currently taking any medication?

Yes No

If Yes, please specify the medication and how long you have been taking it:

4. Do either you or your partner have a disability?

Yes No

If Yes, please give details:

Family Concerns Questionnaire

Please use the space below to give more details about your problem and tell us more about the kind of help you are looking for:

1. What is your current family set up – ie how many children of what ages are living in your household?:

2. Are you currently in a relationship?

Yes No

If Yes, are you living with your partner?

Yes No

3. Are the children in your household also your partners?

Yes No

If No, what are the contact arrangements with their non-resident parent?

4. Does your partner have children that don’t live with you?

Yes No

If Yes, what contact arrangements do they have?:

5. How long have you been living in the current family set up?:

6. If there have been changes in the past 12 months, what have these been and why?:

7. If you are divorced/separated from your children’s other parent, what were the reasons for the separation?:

8. What is the children’s understanding of the reasons for separation?:

9. Are there any other significant adults around who influence your family life, eg grandparents, aunts/uncles, teachers?:

10. Is your child happy at school? If not, how would they describe the problem?

11. When did the problem you’re seeking help for today first start?

12.Have you tried to address the problem directly with your partner, children, your ex or other family members?

Yes No

If yes, please give details of their response and what happened next.

Please use the space below to give more details about your problem and
tell us more about the kind of help you are looking for:
(Note: This box expands to hold as much text as an A4 sheet)

About You...

Gender:

Age:

Sexual Orientation:

Relationship Status:

If you are in a relationship, is your partner aware thatyou are seeking help for this problem?

1. Are your currently suffering any physical or mental illness?

2. Are your currently seeing a doctor/specialist for any physical or mental illness?

If Yes, have you spoken to them about your problem?

3. Are your currently taking any medication?

4. Do either you or your partner have a disability?

Family Concerns Questionnaire

2. Are you currently in a relationship?

If Yes, are you living with your partner?

3. Are the children in your household also your partners?

4. Does your partner have children that don’t live with you?

12.Have you tried to address the problem directly with your partner, children, your ex or other family members?

If you are in a relationship, is your partner aware that
you are seeking help for this problem?