Couples Counseling Intake

1
Please select the state you are located in.
Please Select
Please Select
Michigan
Alabama
Arizona
Arkansas
Colorado
Commonwealth of the Northern Mariana Islands
Connecticut
Delaware
District of Columbia
Florida
Georgia
Idaho
Illinois
Indiana
Kansas
Kentucky
Maine
Maryland
Minnesota
Missouri
Nebraska
Nevada
New Hampshire
New Jersey
North Carolina
North Dakota
Ohio
Oklahoma
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
2
Please select your preference for counseling location.
Ann Arbor
Chelsea
Virtual
3
Your Name* This field is required.
First Name
Last Name
4
Your Email* This field is required.
example@example.com
5
Your Phone Number* This field is required.
Please enter a valid phone number.
6
Date of Birth* This field is required.
Date
Year
Month
Day
7
Partner's Name* This field is required.
First Name
Last Name
8
Partner's Email* This field is required.
example@example.com
9
Partner's Phone Number* This field is required.
Please enter a valid phone number.
10
Partner's Date of Birth* This field is required.
Date
Year
Month
Day
11
Out of Pocket Rate Reminder* This field is required.
12
What are the main concerns?* This field is required.Please select all applicable concerns.
Addiction / Substance Use
Behavioral Issues
Divorce
Family Conflict
Grief
Parenting
Pregnancy, Prenatal, Postpartum
Relationship Issues
Other
13
What medications are the clients currently taking?
14
What is your schedule availability?* This field is required.Please indicate all possibilities. The wait time is longer for evening hours.
Morning (8am - 12pm)
Afternoon (12pm-3pm)
Evening (3pm or later)
15
What are the goals/concerns to work on in counseling?* This field is required.Please also note here if you have a strong preference for a specific counselor and would like to be considered only for their waitlist. Also please note if you have any specific limitations to your availability. This could affect wait time.
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Large
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Ok
Ok
16
How did you hear about us?
Should be Empty: