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 me?*

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 me as your therapist?*

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.

Intake Form – Couples

Couples Intake Form