Lena Fenton: Online Couples Therapy and Sex Therapy

If you are coming as a couple, each partner needs to fill in the questionnaire.

Name*
Prefix First Name Surname
Address*
Street Address Address Line 2 City County Post Code Country
Telephone*
Email*
Date of birth
DD dash MM dash YYYY
Profession
If part of a couple, how long have you been together?
If married, how long have you been married?
If coming as an individual, when have you last been in a relationship and for how long?
With whom do you currently live?
Children (gender/ages) from current or previous relationships:
Please state any previous counselling experience: (Reason/when/for how long)
If you lived away from your parents as a child – please state age/where you stayed/reason away:
Is there/has there been any physical violence in your relationship? If yes, state when:
State any major events impacting on your relationship that have recently happened or are coming up:
GP Details (Emergency Only
Are You Currently on medication?
- Yes
- No
If Yes, Please Give Details:
Is there anything else I should know?
How did you find out about me?
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Intake/consultation form