Couples Intake Form - Couples Counseling Boston

Please fill out this form prior to your couples counseling appointment.

Name

Address (include city, zip)

Your Age

Email Address

Telephone Number

Employment and Current Position, indicate if stay at home parent

How did you learn about my practice

Do you have children? If so what age(s)

Briefly describe your reasons for seeking couples therapy

What do you hope to achieve through couple’s counseling?

Are you currently taking any medications for psychological purposes? Please indicate.

Have you engaged in psychotherapy or couples therapy before? If so when? Briefly describe your experience.

Partners Information

Partners Name

Partners Age

How long have you been together?

Partners Occupation

Partners Telephone Number

Partners Email Address