Homework Assignment

Full Name*

First NameLast Name

E-mail*

Tell me what is going on in your relationship (what are the problems you are facing, what are you unhappy about, what are you (or your partner) complaining about, what is missing, etc. you may be as brief or as wordy as you feel necessary.)*

Tell me how your partner is responsible for what is going on in your relationship*

Tell me how you are responsible for what it going on in your relationship*

If therapy is successful, what would you notice is different about your relationship?*

Finally, what do you think will be required of you for this happen?*

Although I understand that discussing payment is a distraction from the therapy process, please take a minute to confirm your intention to cover the fees related to therapy. Please also confirm that you've read and have understood the page describing my policies for canceling appointments, which can be found under the Office Hours and Fees page of my website or by clicking on this link (will open in a new window). Thank you! I look forward to doing my best to help you.

X

Cancelling Appointments

I understand that appointments need to be canceled. However, there will be a charge for no-shows and any appointments canceled without reasonable notice (24 hours) or a fair explanation. (Sh*t happens, just let me know so I can give the appointment to someone who is waiting!)

Please type your name in the box below to confirm the above.*