What kind of therapy are you interested in?

Personal Information

Partner 1

Male     Female
Partner 2

Male     Female
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Relationship Information

How long have you been together
Are you married
Do you have children

Current Relationship Concerns

What are the primary reasons for seeking couples therapy?

 Therapy Preferences

Preferred mode of therapy
  • Video Call

    Video Call

  • Audio Call

    Audio Call

  • Chat Session

    Chat Session

Preferred time for sessions
Frequency of sessions

Relationship History

Have you previously attended couples therapy
Have either of you attended individual therapy
Partner 1
Are you currently taking any medication for mental health
Do you have any history of mental health diagnoses
Partner 2
Are you currently taking any medication for mental health
Do you have any history of mental health diagnoses

Lifestyle and Support System

Partner 1
How would you describe your current lifestyle?
Do you have a support system in place (family, friends, etc.)?
How often do you exercise?
Do you have any hobbies or activities that help you relax?
Partner 2
How would you describe your current lifestyle?
Do you have a support system in place (family, friends, etc.)?
How often do you exercise?
Do you have any hobbies or activities that help you relax?

Goals and Expectations

What do you hope to achieve through couples therapy
Any specific goals you would like to focus on during the sessions
What are your expectations from the therapist
Is there anything else you would like to share that might help us match you with the best therapist for your needs

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