Couples Counseling Intake

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Please select the state you are located in.
Ann ArborChelseaVirtual
Your Name*

First NameLast Name
Your Email*
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Your Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

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Date
Partner's Name*

First NameLast Name
Partner's Email*
example@example.com
Partner's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Partner's Date of Birth*

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Date
Our commitment is to make quality counseling and events accessible. While our standard session fee is $200, we offer a limited number of reduced rate slots, typically starting from $125, for couples for whom our full fee is not feasible. For rates below $125, additional financial information may be requested to determine eligibility for our sliding scale. Please let us know if you would like to explore these options.

The standard fee works for us.We are interested in discussing reduced rate options.
YesNo
Please briefly describe why you are requesting financial assistance.
Considering your income and essential expenses, what feels like a manageable amount to pay per session/service at this time?
What is your estimated total household income per month (after taxes)?
What are your most essential monthly expenses? (think rent, food, basic utilities, critical medical needs)
Considering your income and essential expenses, what feels like a manageable and fair amount for you to pay per session/service at this time?
Addiction / Substance UseFinancesDivorceFamily ConflictConnectionParentingPregnancy, Prenatal, PostpartumBoundariesIntimacyInfidelityTrust IssuesCommunicationResentmentAffectionRoles (division of labor)Other
Morning (8am - 12pm)Afternoon (12pm-3pm)Evening (3pm or later)
What are the goals/concerns to work on in counseling?*
How did you hear about us?
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