Confidential Couples Counseling Intake Form

Each partner in a couple must complete the Confidential Couples Counseling Intake form and initial The Limits of Confidentiality/Therapy Cancellation Policy & Fees form.

Please complete and submit this form prior to your visit.
  • Date Format: MM slash DD slash YYYY
  • CHILDREN

  • CURRENT RELATIONSHIP CIRCUMSTANCES

  • On a scale of 1-10 rate the level of conflict between you and your spouse

  • On a scale of 1 to 10 rate how well you and your spouse communicate

  • Please remember to complete the The Limits of Confidentiality/Therapy Cancellation Policy & Fees form which is found on our Forms Menu.