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Couples screening form
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15
Questions
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HIPAA
Compliance
1
Your name
First Name
Last Name
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2
Your date of birth
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3
Partner/spouse name
First Name
Last Name
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4
Your partner/spouse's date of birth
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5
Relationship status
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6
How long have you been in a relationship?
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7
Are you in a mutually agreed upon open sexual relationship, i.e., swinging, multiple partners, etc.?
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8
Are children involved?
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9
Why are you seeking relationship counseling?
Check all that apply.
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10
Current legal status
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11
Commitment to the relationship
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12
Please briefly describe your relationship issue.
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13
Email
example@example.com
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14
Phone Number
Please enter a valid phone number.
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15
Would you like to use your insurance benefits?
We accept Blue Cross Blue Shield, Cigna/Evernorth, United, and Aetna insurances.
YES
NO
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