Welcome

Thank you for completing this form in advance of our session together. Please provide as much detail as you feel is relevant.

Personal Information | Family of Origin | Life situation | Relationship

Name *
Name
Date of Birth
Date of Birth
Gender
Address
Address
Phone
Phone
Preferred Method of Contact
Are Your Parents Still Together?
Is There a Family History of Substance Abuse?
Is There a Family History of Emotional of Physical Abuse?
Is There a Family History of Sexual Abuse?
Have You Been to Therapy Before?
Relationship Status
If Partnered, Do You Live Together?
Have There Been Infidelities In Your Relationship?
Do You Have Trust Issues Between You?
Is There Any Substance Abuse Issues?
Is There Physical or Emotional Abuse In Your Relationship?