Contact Information

NEW CLIENT
COUPLE INTAKE FORM

Thank you for considering us for your counseling needs.

To request an appointment we'll need some information from you to get started. Please complete our new client form to save time during our first session. This form includes two sections, one for each participant in the couples therapy session. There is a Partner A and Partner B - please be sure each participant fills their respective sections out completely.  As a suggestion, the participant who carries the insurance should complete the Partner A section.

At the beginning of our first session, our therapist will briefly review the information sheet to make sure I have all information required for my records. We will also explain our policies regarding confidentiality and fees associated with your therapy. Please ask us any questions you have about therapy; as we are here to serve you and to make you comfortable during this process. If you would like a copy of our HIPAA Privacy Practices you can review them here.

Contact Information Partner A

Sex
May we leave a message?
May we send mail to your address?
Marital Status
Appointment Time Preferences

PLEASE COORDINATE PREFERRED APPOINTMENT TIME FOR EACH PARTICIPANT (PARTNER A AND B)

Which week day do you prefer? (select all that apply)
Time of day preferred? (select all that apply)
Therapist Preferences

PLEASE SELECT TWO (2) THERAPIST OPTIONS FROM ONE (1) CATEGORY BELOW

CATEGORY 1 - Licensed

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CATEGORY 2 - Registered

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CATEGORY 3 - Trainee/Intern

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PLEASE SELECT TWO (2) THERAPIST OPTIONS FROM ONE (1) CATEGORY BELOW

CATEGORY 1 - Licensed

CATEGORY 2 - Registered

CATEGORY 3 - Trainee/Intern