Couple Therapy Initial Assessment Note Template
Description:
This template provides a structured framework for therapists conducting an initial assessment session with a couple, capturing essential information about their relationship, and individual histories, and presenting issues to inform a tailored treatment plan. It is designed to assess the couple’s dynamics, strengths, and challenges, with comprehensive guidance within brackets to ensure a thorough evaluation that respects both partners’ perspectives and sets the stage for effective couples therapy.
Note:
This template is intended for the first session with a couple. Adjust sections based on the couple’s dynamics, willingness to engage, or specific therapeutic goals, ensuring sensitivity to relational tension or individual comfort levels.
Date: [Record the date of the initial assessment session to establish the starting point of the couple’s therapeutic record]
Couple Names: [Enter the full legal names of both partners to ensure accurate identification and documentation]
Therapist Name: [Enter the therapist’s full name to establish accountability and authorship of the assessment]
Duration of Relationship: [Note the length of the couple’s relationship, including dating and marriage/cohabitation if applicable, to provide context for their relational history]
Consent and Confidentiality
[Document both partners’ understanding and agreement to the therapy process, including confidentiality limits (e.g., mandatory reporting for harm, no-secrets policy in couples work), noting signatures or verbal consent as required by practice standards and ethical guidelines.]
Couple Information
Partner 1 Name: [Enter the full legal name of the first partner for clarity in record-keeping and differentiation]
Partner 1 Date of Birth: [Record the first partner’s date of birth in MM/DD/YYYY format to confirm their age and provide context for life stage considerations]
Partner 2 Name: [Enter the full legal name of the second partner for clarity in record-keeping and differentiation]
Partner 2 Date of Birth: [Record the second partner’s date of birth in MM/DD/YYYY format to confirm their age and provide context for life stage considerations]
Living Arrangement: [Note whether the couple lives together, separately, or with others (e.g., children, in-laws), to understand their current relational environment]
Presenting Problem & History
Reason for Seeking Therapy: [Describe the primary concerns or issues prompting therapy, as reported by each partner individually and/or jointly, capturing their perspectives on the relationship’s challenges.]
Onset and Duration: [Record when the presenting problems began, how long they have persisted, and any patterns or escalations over time, to establish a timeline of relational difficulties.]
Relationship History: [Detail key milestones in the couple’s relationship, such as meetings, marriage, major conflicts, or separations, to contextualize their current issues within their shared history.]
Previous Therapy Attempts: [Note any past couples or individual therapy experiences, including duration, outcomes, and perceptions of effectiveness, to assess prior efforts at resolution.]
Individual Mental Health/Medical History: [List any relevant past or current mental health diagnoses, medical conditions, or medications for each partner, including dates and impacts on the relationship, to understand individual factors influencing the couple.]
Current Functioning
Partner 1 Observations: [Describe the first partner’s observable behaviors, emotional state, and engagement during the session, such as tone, body language, or openness, to assess their current relational stance.]
Partner 2 Observations: [Describe the second partner’s observable behaviors, emotional state, and engagement during the session, such as tone, body language, or openness, to assess their current relational stance.]
Couple Dynamics: [Record the observed interactions between partners, such as communication patterns, conflict style (e.g., avoidance, escalation), or affection, to evaluate the relational interplay in-session.]
Reported Strengths: [Note any strengths or positive aspects of the relationship reported by either partner (e.g., loyalty, shared goals), to identify resources for therapy.]
Family and Environmental Context
Family Background: [Detail each partner’s family of origin, key relationships, and dynamics (e.g., divorce, closeness), to explore how upbringing may shape current relational patterns.]
Children or Dependents: [List any children or dependents, their ages, and roles in the relationship, to assess family stressors or responsibilities affecting the couple.]
External Stressors: [Note external influences like work pressures, financial strain, or social conflicts, to identify contextual factors impacting the relationship.]
Risk Assessment
[Document any reported or observed risks, such as domestic violence, substance abuse, or suicidal ideation from either partner, including severity, frequency, and safety measures, to prioritize immediate safety and guide interventions.]
Strengths and Interests
Couple Strengths: [Highlight shared strengths or positive attributes of the relationship (e.g., commitment, humor), to build on in therapy and foster hope.]
Individual Interests: [List each partner’s hobbies or passions (e.g., sports, music), to leverage as coping tools or connection points in treatment.]
Goals for Therapy
Partner 1 Goals: [Describe what the first partner hopes to achieve through therapy, capturing their individual priorities or desired changes in the relationship.]
Partner 2 Goals: [Describe what the second partner hopes to achieve through therapy, capturing their individual priorities or desired changes in the relationship.]
Therapist’s Initial Goals: [Outline preliminary therapeutic objectives based on the assessment, such as improving communication or rebuilding trust, to set a direction for treatment.]
Next Steps
[Detail the proposed frequency and format of future sessions (e.g., weekly joint sessions, occasional individual check-ins), what to expect initially, and how the couple can contact the therapist, to establish a clear plan and communication pathway.]
Summary and Initial Impressions
[Summarize the therapist’s initial understanding of the couple’s situation, integrating presenting problems, dynamics, and strengths, to provide a cohesive overview for guiding therapy.]
Plan for Treatment
[Outline the preliminary treatment approach, including potential modalities (e.g., EFT, Gottman Method), focus areas, or immediate actions (e.g., safety planning), to initiate a tailored therapeutic process.]
Therapy Couple Initial Assessment Note Template (Filled Mock Session)
Date: February 25, 2025
Couple Names: Alex Torres and Maria Torres
Therapist Name: Dr. Laura Kim, LMFT
Duration of Relationship: 8 years (dated 3 years, married 5 years)
Consent and Confidentiality
Both Alex and Maria signed the consent form, agreeing to therapy and understanding confidentiality limits (e.g., no-secrets policy, reporting harm). They verbally confirmed their willingness to proceed jointly.
Couple Information
Partner 1 Name: Alex Torres
Partner 1 Date of Birth: 06/10/1988
Partner 2 Name: Maria Torres
Partner 2 Date of Birth: 09/22/1990
Living Arrangement: Live together in a two-bedroom apartment with their 3-year-old son, Mateo
Presenting Problem & History
Reason for Seeking Therapy: Alex says, “We argue all the time and don’t connect anymore.” Maria adds, “He’s checked out, and I’m exhausted fixing it.”
Onset and Duration: Conflicts escalated 2 years ago after Mateo’s birth, with weekly arguments for the past year over parenting and intimacy.
Relationship History: Met in 2017 at work, married in 2020. The early years were “fun and easy,” but stress grew with parenting and Maria’s job loss in 2023.
Previous Therapy Attempts: Tried couples counseling in 2023 (3 sessions, “didn’t click with the therapist”). Alex saw a therapist solo in 2021 for stress (6 sessions, helpful).
Individual Mental Health/Medical History: Alex: was diagnosed with mild depression in 2021, with no current meds. Maria: no diagnosis, takes birth control, history of migraines.
Current Functioning
Partner 1 Observations: Alex spoke softly, arms crossed, avoiding eye contact with Maria. He engaged more when discussing work, showing mild frustration.
Partner 2 Observations: Maria was animated, tearing up when discussing loneliness, but softened when Alex spoke. She leaned forward, eager to explain.
Couple Dynamics: Frequent interruptions, raised voices initially, but both paused when prompted. Little warmth was observed, with tension easing slightly by the end.
Reported Strengths: Alex: “We’re both stubborn—that’s kept us together.” Maria: “We love Mateo and want to make this work.”
Family and Environmental Context
Family Background: Alex: grew up with distant parents, and values independence. Maria: close-knit family, feels Alex rejects her relatives.
Children or Dependents: Mateo, age 3, is in daycare; parenting disagreements are a major conflict source.
External Stressors: Maria’s recent job loss (3 months ago), Alex’s long work hours (50+/week), and tight finances strain their dynamic.
Risk Assessment
No domestic violence or suicidal ideation was reported. Alex drinks 3-4 beers nightly; Maria worries it’s “too much,” but no abuse is evident. Safety is not a concern now.
Strengths and Interests
Couple Strengths: Shared commitment to parenting, history of resilience (e.g., surviving job loss), and mutual humor noted in early years.
Individual Interests: Alex: enjoys hiking and video games. Maria: loves cooking and reading romance novels.
Goals for Therapy
Partner 1 Goals: Alex: “Stop fighting so much and feel like a team again.”
Partner 2 Goals: Maria: “Reconnect emotionally and share parenting better.”
Therapist’s Initial Goals: Improve communication, rebuild emotional intimacy, and address parenting roles.
Next Steps
Weekly 60-minute joint sessions are scheduled for Tuesdays at 6 p.m., starting March 4. Initial focus on de-escalating conflict. Contact me at laura.kim@therapy.org or 555-654-3210.
Summary and Initial Impressions
Alex and Maria are a married couple of 5 years facing disconnection and frequent conflict, worsened by parenting stress and external pressures. Strengths include commitment and shared history, but poor communication and emotional distance are key challenges.
Plan for Treatment
Begin with Gottman Method techniques (e.g., softening startup) to improve communication, explore individual stressors via EFT, and assign a shared activity to rebuild the connection.