RELATIONSHIP COUNSELING
By filling out this form, you have given me permission to make contact with you via the details provided for the referral of counseling services. For more information about the counseling practice go to www.groundinghearts.com/viergelyn
Please read below
PRIMARY LEGAL FULL NAME
*
FIRST NAME
LAST NAME
PARTNER'S LEGAL FULL NAME
*
FIRST NAME
LAST NAME
Primary Email
*
example@example.com
Primary Phone Number
*
-
Area Code
Phone Number
Is your partner aware you are seeking couples/relationship counseling?
*
YES
NO
Other
Please explain your primary reason for relationship/couples counseling
*
Are there any current or future legal concerns ?
*
YES
NO
In the past 6-months, have you or your partner had in-patient hospitalization, Intensive Outpatient Program (IOP), Partial Hospital Program (PHP) or terminated a counseling relationship?
*
YES
NO
Are you or your partner currently taking prescribed medication for a mental health condition?
*
YES
NO
WHAT DAY OF THE WEEK
*
TUESDAYS (10-2, 4-6PM)
WEDNESDAYS (10-2, 5-7PM)
FRIDAYS (10-2, 4-6PM)
Are you or your partner seeing an individual therapist for any mental health condition?
*
From section above, what are your MOST flexible days/times you are available for sessions?
*
I agree that couple or relationship counseling is private pay/self-pay, and that no medical diagnoses will be made during the course of my couple or relationship treatment.
*
YES
NO
This question is important. Do you foresee any future circumstances that may impact/interfere with attending counseling sessions? (For example, changes in work schedule, traveling more than 14 days, moving further away, childcare, medical procedures, legal proceedings) etc.
*
YES
NO
Anything else you want me to know?
Submit
Should be Empty: