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INTAKE

Background information & relationships

EN - Intake Form (background information) (#31)

Your name


Please enter the name of your partner with whom you will be attending the sessions

Demographic informationen


Information zur Beziehung


Information about the deceased partner


Please enter the details (name and date of birth) of all your children below. Use the "plus" symbol on the right-hand side to add a child.

Marriage history


Perceived quality of your current relationship


0

Further questions on relationship quality

The following sections relate to the quality of your relationship. Please answer questions on a scale of 0-4 where,

0 = Never true;
1 = Rarely true;
2 = Sometimes true;
3 = Usually true;
4 = Always true.

  


The following questions are about how ACCESSIBLE your partner is to you from your viewpoint

0
0
0
0
0

The following questions are about how ACCESSIBLE you are for your partner from your viewpoint

0
0
0
0
0

The following questions are about how RESPONSIVE your partner is to you from your viewpoint

0
0
0
0
0

The following questions are about how RESPONSIVE you are to your partner from your viewpoint

0
0
0
0
0

The following questions are about how emotionally ENGAGED you are with your partner

0
0
0
0
0

The following questions are about how emotionally ENGAGED your partner is with you

0
0
0
0
0
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