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Intake Form – Couples
Intake Form – Couples
Couples Intake Form
We are:
*
Select...
Married
Engaged
Committed
Dating
Other
Partner One Name
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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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Partner Two Address (leave blank if same)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
How did you find me?
*
Select...
Referred by a therapist
Referred by a friend
I met Jonathan Zalesne in person
Psychology Today Website
Goodtherapy Website
Theravive Website
ICEEFT Website
Marriage Friendly Therapists Website
Google Search
Bing Search
Other Internet Search
Other
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
.