Couples Counseling Consent and Intake Form
Consent
We consent to participate in couples counseling services.
Additional Notes or Concerns:
Partner 1 Information
Full Name:
Date of Birth:
Phone:
Email:
Address:
Partner 2 Information
Full Name:
Date of Birth:
Phone:
Email:
Address:
Relationship Information
Length of Relationship:
Marital Status:
Married
Engaged
Dating
Separated
Other
Any children together? If yes, ages:
Presenting Concerns / Goals
Please describe the main reasons you are seeking counseling:
What are your goals for counseling?
Previous Counseling
Have you had previous couples or individual counseling? If yes, please elaborate:
Confidentiality
Information shared is confidential except in situations involving harm to self or others, abuse, or as required by law.
Agreement
Partner 1 Signature:
Date:
Partner 2 Signature:
Date: