Couples Information Sheet
Today's Date
*
-
Month
-
Day
Year
Date
Client's Name
*
First Name
Last Name
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Pronouns
Client's Cell Phone
*
Client's Email
*
example@example.com
Employer/School
Client's Address
*
Street Address
Apt/Suite
City
State / Province
Postal / Zip Code
May we add you to our mailing list?
*
Please Select
Yes
No
Spouse/Partner's Name
*
First Name
Last Name
Spouse/Partner's Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Pronouns
Employer/School
*
Spouse/Partner Address (if living separately)
Street Address
Apt/Suite
City
State / Province
Postal / Zip Code
Spouse/Partner's Cell Phone
*
Spouse/Partner's Email
example@example.com
Emergency Contact Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Relationship
Insurance Information
Insurance Company's Name
ID Number
Group Number
Member's Name
First Name
Last Name
Member's Date of Birth
-
Month
-
Day
Year
Date
Members's Relationship to Client
EAP Information (If Applicable)
EAP Provider's Name
EAP Authorization No.
No. of Authorized Visits.
Family Information
Childrens' Name and Ages (If Any)
Relationship Status
*
Married
Engaged
Dating
Co-Habitating
Separated
Date Of Marriage/Committment
-
Month
-
Day
Year
Date
Client's Previous Marriage?
*
Yes
No
Spouse/ Partner's Previous Marriage?
*
Yes
No
Have you had previous experience with couples counseling
*
Yes
No
If yes, how long ago?
Please describe the reasons for couples counseling at this time?
*
What are you and your spouse/partner's goals for couples counseling?
*
How were you referred to The Genesis Therapy Center
*
Online Search
EAP Provider
Insurance
Former/Current Client
Family/Friend
Submit
Should be Empty: