Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Gender

Female

Male

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Preferred Method of Contact

Phone

Email

Have You Been to Therapy Before?

Yes

No

Relationship Status

Single and Dating

Single and Not Dating

Committed Relationship

Domestic Partnership

Married

Separated

Divorced

Widowed

Other

Have There Been Infidelities In Your Relationship?

Yes

No

Don't know

Do You Have Trust Issues Between You?

Yes

No

Is There Any Substance Abuse Issues?

Yes

No

Is There Physical or Emotional Abuse In Your Relationship?

Yes

No