Next Steps

Preferred Name of Person 1

First Name

Last Name

Legal Name of Person 1 *

First Name

Last Name

Date of Birth- Person 1 *

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DD

YYYY

Phone Number-Person 1 *

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Preferred Name of Person 2

First Name

Last Name

Legal Name- Person 2 *

First Name

Last Name

Date of Birth- Person 2 *

MM

DD

YYYY

Phone Number- Person 2 *

(###)

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Have you been in couples therapy before? *

Yes

No

I'm Interested in working on: *

To your degree of comfort, please check all that apply. This list is not meant to be conclusive, but can give me a sense of how I can help.

Communication during conflict (eg. shutting down, yelling, stonewalling)

Frequent Arguments or Conflict

Sexual Dysfunction

Trauma Responses

Emotional disconnection or growing apart

Difficulty Controlling Anger

ADHD Symptoms Impacting Relationship

Navigating infidelity or betrayal

Conscious Uncoupling

Relationship Discernment

Difficulty expressing needs/wants

Difficulty expressing emotions/feelings

Power struggles or control issues

Parenting disagreements

Coparenting challenges

Financial disagreements

Division of Labor

Substance use affecting the relationship

Jealousy, Envy or Porssessiveness

Setting Boundaries

Interracial/Intercultural Differences

Attachment differences (anxious, avoidant, preoccupied, disorganized)

Relationship Insecurity/Anxiety

Exploring or negotiating non-monogamy

Repairing after separation or trial break

Life Transitions impacting the relationship (eg, moving, career change, becoming parents, loss)

Healing from past relationships or trauma within the current relationship

Premarital or pre-commitment Counseling

Codependency patterns

Differing needs for space, autonomy or connection

Improving emotional safety and vulnerability

Lack of healthy individuality

Other

What Frequency of Sessions are you hoping for? *

Let me know if you're seeking biweekly, weekly, or either. I always recommend weekly as it's clinically more supportive to start.

Weekly Sessions

Biweekly Sessions

Either/Or

Availability *

Please check the boxes for days you are available for sessions

Tuesday

Wednesday

Thursday