Assessment & Plan Elements
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Marital/Relationship Status:
Single
Not Currently In A Relationship
Never In A Serious Relationship
Never Married
Currently in a relationship that has lasted

Recent Breakup W/ Significant Other
Recently out of a relationship that lasted

Multiple Partners
Currently In A Serious Relationship
Unmarried Living W/ Partner
Engaged
Previously Engaged
In Casual Relationship/Dating
Married
In A Relationship
Prior Marriages (Self)
Living With But Separated From
Prior Marriages (Partner)
Currently Separated
Partner Having An Affair
Having An Affair
Separated
separated for
Legally Separated
Divorce In Process
divorced

# Divorced times
remarried

change in family structure (separation from partner)

divorced for
Widowed
Spouse
Partner:
Age:
Pt Partner Has Hx Of
Significant Health Concerns/Illnesses Of Partner-Psychosocial Impact
Very Satisfied With Relationship
Satisfied With Relationship
Somewhat Satisfied
Dissatisfied With Relationship
Very Dissatisfied With Relationship

Marital/Relationship Status:
Single
Not Currently In A Relationship
Never In A Serious Relationship
Never Married
Currently in a relationship that has lasted

Recent Breakup W/ Significant Other
Recently out of a relationship that lasted

Multiple Partners
Currently In A Serious Relationship
Unmarried Living W/ Partner
Engaged
Previously Engaged
In Casual Relationship/Dating
Married
In A Relationship
Prior Marriages (Self)
Living With But Separated From
Prior Marriages (Partner)
Currently Separated
Partner Having An Affair
Having An Affair
Separated
separated for
Legally Separated
Divorce In Process
divorced

# Divorced times
remarried

change in family structure (separation from partner)

divorced for
Widowed
Spouse
Partner:
Age:
Pt Partner Has Hx Of
Significant Health Concerns/Illnesses Of Partner-Psychosocial Impact
Very Satisfied With Relationship
Satisfied With Relationship
Somewhat Satisfied
Dissatisfied With Relationship
Very Dissatisfied With Relationship


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