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Couples and Family Intake Form

Primary Contact Information

First name*

Last name*

Preferred Name

Age*

Birthday*

Month

Day

Year

Sex at Birth*

Male

Female

Prefer Not to Say

This is for the purposes of billing your insurance company. If you prefer not to say or do not plan to use your insurance, please select “prefer not to say”.

Preferred Pronouns

Email*

Phone*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Insurance Information

Insurance Type*

Insurance ID*

If self-pay, please enter N/A

Policy Holder's Name*

If self-pay, please enter N/A.

Policy Holder's Date of Birth*

Month

Day

Year

If self-pay, please enter N/A

Do you have secondary insurance?*

Yes

If you have a secondary insurance policy and fail to supply that information, you may be held responsible for the full balance of sessions.

Secondary Insurance Type

Secondary Insurance ID

Secondary Insurance Policy Holder's Name

Secondary Insurance Policy Holder's Date of Birth

Month

Day

Year

Therapy Questionaire

Are you currently in therapy?*

Yes

Have you been in therapy before?*

Yes

Most Recent Time in Therapy

Month

Day

Year

Have you had any previous hospitalizations for mental health or substance use concerns?*

Yes

If yes, please explain.

Are you currently taking psychiatric medications for:

Anxiety

Depression

Other

Please list your current medications:

Are you currently facing legal action(s)/child custody issues?*

Yes

If yes, please explain:

Please give us a brief description of your concerns and goals for therapy.*

If you would like to request a specific counselor, please indicate below.

How were you referred to us?

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Couples and Family Intake Form

Primary Contact Information

Insurance Information

Therapy Questionaire