Couples Therapy Treatment Plan Agreement

Client Information

Partner 1 Name:

Partner 2 Name:

Date:

Purpose of Therapy

Goals of Therapy

Session Structure

Session Frequency:

Session Length:

Location:

Roles and Responsibilities

Confidentiality

Cancellation Policy

Payment Agreement

Consent and Agreement

We, the undersigned, agree to the terms outlined above and wish to proceed with couples therapy as described in this agreement.