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Email

Phone Number

Partner's Full Name (if applicable)

Partner's Email (if applicable)

Partner's Phone

If you plan to use work benefits, please let us know: a) what type of counselor is covered by your insurance, and b) what is the annual coverage limit per person. Couple Health has a Registered Social Worker on staff.

What kind of counseling are you looking for?

Individual

Couple

Sex Therapy

Other

Briefly describe your current challenges.

Your flexibility with appointment times will determine how soon we can offer you an appointment. Please let us know your ideal daytime availability for appointments (limited availability for early evening).

Mid to Late Morning

Early Afternoon

Late Afternoon

Other

Please describe any other availability issues.

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