WelcomePlease click the link below to fill out the couples intake form. Couples Intake Form Couples Intake Form Name * First Name Last Name Email * Birthdate Medications Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name, Relationship, and Phone Number Couples Intake Questionnaire What can I help you and your partner accomplish? Have you (or your partner) sought therapy in the past? If so, anything negative or positive you experienced in that treatment? Have you (or your partner) ever had mental health emergencies in the past? Crises such as: panic attacks, debilitating depression, suicidal feelings and/or attempts, any hospitalizations for mental health? If so, how long ago and what was the treatment for it? Do your conflicts ever escalate beyond anything verbal? What time would be best in your schedule to meet for therapy? In session, would a more direct/challenging approach or collaborative/supportive approach be beneficial; what is the best fit for your style of communication? Is there anything else you would like me to know about you? Any other questions for me? Thank you!