Marriage/Couples Therapy Intake Form
Marriage/Couples Therapy aims to relieve stress and improve life between couples. Individuals often seek marriage/couples therapy when they have conflicting viewpoints and ideologies. For more information please visit: https://www.psychologytoday.com/us/basics/therapy/how-does-couples-therapy-work. 

Please note that this is a request to start services. Someone from our office will contact you within 24 - 48 business hours to schedule.
Sign in to Google to save your progress. Learn more
Email *
Date *
MM
/
DD
/
YYYY
Client First Name *
Client Last Name *
Custodian/Guardian Name (if applicable)
Primary Language *
Client Date of Birth *
MM
/
DD
/
YYYY
Client Gender *
Client Race *
Physical Address *
Zip Code *
Home Number *
Cell Number *
Is it okay to leave a voicemail on this number? *
Is it okay to send a text message to this number? *
Primary Care Provider
Primary Care Provider Telephone #
Availability *
Reason For Referral *
How did you hear about us? *
Comments
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Changing Tides Counseling & Behavioral Health LLC. Report Abuse
Google Forms