The Bath Couples Therapy Practice

15 Questions (6 to 10 minutes)

One questionnaire per partner

(1) Are you enquiring as a couple or individually at this stage?

Individually (my partner may join later)

Individually (I am unsure if my partner will take part)

(2) What has led you to consider seeking support at this point?

Please provide only a brief overview relevant to your enquiry.

(3) When we try to talk about difficult issues, which best describes what typically happens?

You may wish to mention any recent events, ongoing patterns, or concerns about how the relationship feels.

We can usually stay engaged, even if it is difficult

We sometimes become overwhelmed or shut down, but can recover and continue

We often become overwhelmed, and it is difficult to continue the conversation

At present, we are unable to have even brief, supported conversations about difficult issues without becoming overwhelmed, shutting down, or escalating, and we are not able to regain enough calm or understanding to continue.

(4) At present, I struggle to see anything positive in my partner or to feel warmth, respect, or goodwill toward them, even outside of conflict.

Does not describe us

Describes us somewhat

Describes us very well

(5) If you were to begin therapy, what would your approach most likely be?

I would be willing to actively take part, even if some aspects feel challenging

I would attend and see how it goes, but I am uncertain how involved I would be

I would attend mainly to support my partner or keep things stable

I am not sure I would want to engage in the process

(6) Has your partner ever been physically aggressive or threatening towards you?

(7) Do you currently have any fear that your partner may become physically aggressive?

(8) Are any of the following currently relevant?

Significant mental health difficulties

Substance use affecting day-to-day life

Harmful or destructive patterns of interaction, such as ongoing anger, contempt, deception, or patterns of behaviour that undermine trust or emotional safety

(9) If a suitable therapy space is not immediately available, how would you feel about waiting for a future appointment?

I'd choose to wait for a place to be available at Bath Couples Therapy

I'd choose to wait, but may also seek support elsewhere in the meantime

I am unsure whether I would stay engaged over a longer wait

I would likely need something more immediate

(10) Your partner's first name

Please only provide your partner’s name with their awareness.

(11) What feels most central in the relationship difficulty?

Please select the closest fit.

Communication breakdown and conflict escalation

Emotional disconnection

Trust rupture or infidelity

Life stressors or external pressures

Differences in values, habits, interests or life direction

Other (brief description)

(12) How would you describe your current thinking about the future of the relationship?

I want to work on the relationship

I am unsure and trying to decide

I feel largely ready to end the relationship

We have already taken steps toward separation

(13) Regular Appointment Availability

To help me plan my waiting list, please indicate the days and approximate times when you would usually be able to attend a regular weekly therapy appointment. As some time may pass before an appointment becomes available, your circumstances may naturally change.

When you reach the top of the waiting list, I will do my best to offer you an initial assessment appointment that fits the availability you have provided. If no suitable regular appointment is available at that time, I will contact you to discuss your current availability before offering the appointment to another couple.

Appointments are ordinarily arranged as a regular weekly or fortnighly appointment reserved exclusively for you while we are working together.

Appointments available: 10:00-15:00 & 19:30-22:00

For example: <12pm • >=2pm • Anytime • NUA (Not Usually Available) • NA (Never Available)

Appointments available:10:00-15:00

Appointments available: 8:00-22:00

Appointments available: 10:00-15:00

Appointments available: 8:00-19:00

Are there any regular times that would not be possible (e.g. shift work, travel, school runs, caring responsibilities)?

For example, shift work, caring responsibilities or other recurring commitments.

(14) Preferred frequency of sessions

(15) Any other information you like to share

Please provide only a brief overview relevant to your enquiry.

All information is handled securely and in accordance with the Privacy Notice.

I have read the Privacy Notice.

I understand that the information I provide will be used to respond to my enquiry and consider the most appropriate next step.

The Bath Couples Therapy Practice

Your email

Your first name