Client Intake Couples Counseling

Name*

First NameLast Name

Phone Number*

E-mail*

example@example.com

1. Session Type Preference*

2. What is your availability/urgency to start*

3. Preferred Time to Reach Out*

4. For Couples Therapy: How willing are you to commit to the process of therapy to see lasting outcomes?*

5. Which of our services are you interested in, select all that apply:*

6. Anything you feel is important for us to know*

0/80

Important Information:

This form is encrypted, though no electronic transmission can be guaranteed 100% secure.
You may choose to skip answering any question you feel infringes on personal information you do not wish to disclose.
We will review your information within 1-2 business days and contact you to schedule your first appointment or consultation call.
If we're aligned, we'll schedule your first session.
We are not a crisis center: if you are experiencing a mental health crisis, please contact:

988 Suicide & Crisis Lifeline: Call or text 988
Crisis Text Line: Text HOME to 741741
National Domestic Violence Hotline: 1-800-799-7233
Emergency Services: Call 911

Inclusivity:

Union Station Therapy welcomes individuals and couples from all backgrounds who are serious about relationship growth. We provide respectful, professional care to everyone and believe that every person deserves compassionate, respectful care regardless of background, beliefs, or life circumstances. Our practice serves people of all faiths, cultures, ages, and relationship structures.

I have read and understood the information provided above regarding security, response time, crisis resources, and the nature of this initial contact. I understand that this submission does not establish a therapeutic relationship.*

I understand & consent to submit