Couples Intake Form



Please fill out this information form as carefully and as thoroughly as possible. The information you provide protected as confidential information. Please use the reverse side of the last page if you wish further space for any of the questions.

If for any reason you do not feel comfortable completing any of the information in the form please let your therapist know



Please do not include phone numbers at which you do not wish to be contacted.

Emergency Contact

Current Marital Status

Family Information

Medical Information

Psychological Information

Have either of you ever received psychotherapy, counselling, or other treatment for personal and/ or marital problems?