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aclestra centre

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- About Us

aclestra centre

Our Practice
Services
Contact us
- About Us

My Relationship Experience

Client info

Name *

Email Address *

Partner's name

Who wanted to try therapy?

Relationship goals

What would you like to see change in your relationship?

Improve communicationGet better at conflictGet better at problem solving togetherImprove parenting togetherImprove intimacy and sexMore physical contact and affectionImprove power and control dynamicsBetter balance of togetherness and independenceHave more fun and laughterFeel closer and more lovedOther

What else would you like to see change in your relationship?

Strategies

What have you tried?

Counselling - individualCounselling - couple /familySelf-help (books, websites, videos or articles)Other

What else can you tell me about what you've tried?

Your role

What could you do better?

Relationship stressors

What added stresses do you feel are affecting your relationship?

Health issuesParenting, co-parenting or step-parentingFinancial difficulties or unemploymentExtended family conflictMental health or addiction issuesSexual dysfunctionEmotional, physical or mental abuseInfidelity or previous separationsGrief and lossCare giving aging parents or other family membersOther

What else can you tell me about the stresses affecting your relationship?

Relationship strengths

What do you do well as a couple?

Socialize togetherHandle finances togetherMake decisions & plan togetherProblem solve & handle conflictDeal with extended familyParent, co-parent or step-parentCommunicate about feelingsShare intimacy and sexShop & make purchases togetherHousework & household choresDisplay affection through physical touch, gifts, acts of service, quality time or words of affirmationFind humor in daily interactionsHave fun & explore togetherShare downtime and holidays togetherOther

What else can you tell me about what you do well as a couple?

Consent *

I understand that the information I have provided is for therapeutic purposes only and that I am providing it voluntarily. I understand that the data is relayed to my counsellor at the Aclestra Centre and will not be shared with anyone else without my expressed consent.

Please do not fill in this field.

Have a question?

We would like to help, but we can't if we don't know what you are thinking.

So tell us - how can we help?

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Convenient scheduling

Online or in-person, daytime, evenings or weekends, in an office or take it outside.

What works for you?

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Learn more

ADHD

Concussion

Counselling

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