Group / Family Therapy

Group & Family Therapy

FORM
Group Therapy Intake Form
I appreciate your interest in group or family therapy. This form helps us understand your needs and schedule your sessions accordingly. Please complete the information below with as much detail as possible.
INSURANCE & PAYMENT OPTIONS
Insurance Type: (Please select one from the dropdown menu)
If you choose this option, you agree to pre-purchase five consecutive sessions with one reschedule session allowed out of the five. There are no refunds, even if you do not complete your sessions.
SESSION PREFERENCES
Please select your preferred session type

Group TherapyFamily Therapy60-minute session 45-minute sessionPlease select your preferred session length:
Please select your preferred session type

Mode of Therapy:Zoom (Virtual) In-Person
ABOUT GROUP/FAMILY THERAPY
Group and family therapy provide a supportive setting for multiple individuals to work through shared concerns under the guidance of a skilled therapist. Whether in a family or therapy group, participants gain insight, strengthen relationships, and develop healthier communication patterns. Depending on your preference, sessions may be conducted via Zoom or in person.
CLIENT INFORMATION
Primary Contact Name
Date of Birth

MonthDayYear
Date
Phone Number:
Email:
Additional Participants (if applicable):
1. Name & Relationship:
2. Name & Relationship:
3. Name & Relationship:
SCHEDULING PREFERENCES
Please provide the day(s) of the week you are interested in and possible time slots. The requested time is not guaranteed.
Preferred Day(s):
Preferred Time(s):
THERAPEUTIC GOALS
What brings you into therapy?
What is your motivation for therapy?
CONSENT & AGREEMENT
Signature: Date

Clear
FOR OFFICE USE ONLY
I acknowledge that all information provided is accurate to the

best of my knowledge. If selecting the Promotion option, I
Assigned Therapist
understand that the purchase is non-refundable, even if I do
Session Start Date

MonthDayYear
Date
Additional Notes
Signature: Date

MonthDayYear
Date
Thank you for completing this form. We look forward to supporting you on your journey to healing and growth!
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Group & Family Therapy

Group Therapy Intake Form

INSURANCE & PAYMENT OPTIONS

SESSION PREFERENCES

ABOUT GROUP/FAMILY THERAPY

CLIENT INFORMATION

SCHEDULING PREFERENCES

THERAPEUTIC GOALS

CONSENT & AGREEMENT

FOR OFFICE USE ONLY