Relationship Intensive Intake Request
Welcome!

Please fill out this form in order to begin your Relationship Intensive Intake process. Once received, you'll be contacting via email to set up your free consultation call to help you decide if a Relationship Intensive is right for you and your partner.

Thank you!

**** CONFIDENTIALITY NOTICE ****

Please note: GoogleDocs, GoogleForms, and/or email are not secure or confidential ways to communicate. Never send sensitive or confidential information via these formats unless you have carefully considered the risks in doing so.

Please only use this GoogleForm to request an intake appointment if you have considered the confidentiality risks of doing so.

Your Name: *
Your answer
Your pronouns (optional):
Your answer
Your Partner's Name: *
Your answer
Your partner/s pronouns (if applicable)
Your answer
Your email: *
Your answer
Your phone number: *
Most scheduling communication will happen over email, but it's always helpful to have a number just in case.
Your answer
Please three dates that would work for you to schedule your initial, in-person therapy intensive: *
Initial therapy intensives take place between 10am-5:30pm with a lunch break and extra break and meet in-person at the Soma Wellness Center in Brattleboro, VT. Your subsequent 75-minute sessions (3 in total) can take place in-person at the Couples Center or online via video chat.
Your answer
Which Relationship Intensive Package are you interested in? *
Required
If you are interested in a Custom Relationship Package, please provide a little bit of information about what you're looking to work on in your intensive:
Details about your customizations will be gathered during your free consultation call so please leave a brief description.
Your answer
Please provide a brief description of what you and your partner are looking to accomplish during your Relationship Intensive: *
Your answer
What general days & times might work for you and your partner to schedule your free video chat consultation call in the next 2 weeks? *
Your answer
Anything else that's important for me to know about your intake?
Your answer
Please check here to indicate that you've read & understand the following details about Relationship Intensives. Formal paperwork will be provided and signed when you choose to book your intensive. *
Relationship Intensives begin in person at the Soma Wellness Center in Brattleboro, VT and meet from 10am-5:30pm wth a lunch break and additional break. Subsequent 75-minute sessions (3 in total) can take place either in-person in Brattleboro, VT or online via video chat. All Relationship Intensives cost $2,700 in total. A 50% non-refundable deposit of $1,350 is due upon sign-up in order to hold your initial intensive date. The remainder of the full cost of the intensive ($1,350) is due at the start of your first session and is non-refundable regardless of whether or not you choose to complete the three sessions after your 8-hour intensive appointment. **No insurances are accepted** Payments can be made via cash, check, Venmo, or PayPal.
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