COUPLES THERAPY- REQUEST FORM

Couples therapy can support you and your partner with the following:

-Communication breakdowns or conflict
-Navigating disconnect, distance or feeling 'stuck'
-Rebuilding trust after rupture or hurt
-Intimacy challenges or emotional barriers
-Understanding attachment and communication styles
-Differences in expectations, needs, values or decision making
-Navigating life transitions (moving in together, parenthood, family dynamics or career changes)
-Preventative support to strengthen a healthy relationship

Fees and session details:

Couples therapy sessions are $200 AUD per 60-minute session, or $220 AUD per 90-minute extended session. Payment is required on the day of the session.

(Prices listed are GST-exclusive)

Name

First NameLast Name

Name

First NameLast Name

Email

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Email

example@example.com

Phone Number

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Phone Number

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Occupation

Have you engaged in couples therapy before? If so, how long for?

What has led you to seek couples therapy at this time?

What feels most challenging in your relationship right now?

Are there any recurring patterns, arguments, or dynamics you find yourselves stuck in?

Are there specific topics you'd like support with? (Check all applicable)

Preferred days for sessions

MondayTuesdayWednesdayThursday

Preferred times for sessions

Morning (10am- 12pm)Afternoon (12pm- 4pm)Evening (4pm- 6pm)