Couples Therapy

Couples Therapy Intake Form

Insurance Information

Who is completing this form?

Please select one option

If completing on behalf of your partner, please confirm

Reason for Seeking Therapy

Select all that apply

Therapeutic Goals

Additional Information

Expectations & Acknowledgment

By submitting this form, you acknowledge that therapy is a collaborative process that requires openness and commitment from both partners. Our goal is to create a balanced and productive space for healing, growth, and meaningful progress.