Intake Form – Couples - Colorado Center for Couples and Families

Couples Intake Form

Couples Intake Form
We are:*
Partner One Name*
First Name Last Name
Partner Two Name*
First Name Last Name
Partner One Nickname*
What would you like me to call you in therapy? For example, if your first name is Jonathan but you would prefer to be called Jon, type Jon here. If you just want me to use your first name, retype your first name here.
Partner Two Nickname*
What would you like me to call you in therapy? For example, if your first name is Jonathan but you would prefer to be called Jon, type Jon here. If you just want me to use your first name, retype your first name here.
What is Partner One's email address?*
Enter Email Confirm Email
What is Partner Two's email address?*
Enter Email Confirm Email
What is Partner One's cell phone?*
If Partner One has no cell phone, enter the best phone number for us to reach Partner One.
What is Partner Two's cell phone?*
If Partner Two has no cell phone, enter the best phone number for us to reach Partner Two.
What is Partner One's gender identity?*
For example: Male, Female, Trans-man, Trans-woman, etc...
What is Partner Two's gender identity?*
For example: Male, Female, Trans-man, Trans-woman, etc...
What is Partner One's birthday?*
MM
DD
YYYY
What is Partner Two's birthday?*
MM
DD
YYYY
Partner One Home Address*
Street Address Address Line 2 City State ZIP Code
Partner Two Address (leave blank if same)
Street Address Address Line 2 City State ZIP Code
How did you find us?*
What is this person's name?*
May I thank this person for the referral?*
- Yes, you may thank them for the referral
- No, please do not let them know I contacted you
What were the factors that influenced you to consider choosing us as your therapists?*
Agreement*
- By checking this box and clicking the Agree and Submit button below, you (1) give us permission, on the phone numbers provided in this form, to call you and your partner, text you and your partner, and to leave voice mails in which we identify ourselves, (2) give us permission to e-mail you and your partner at the e-mail addresses provided in this form, and (3) acknowledge and accept our privacy policy.