Client Forms

If you have made your first appointment, please find the appropriate forms below as was indicated to you by your therapist. You may either fill them out on your computer (Word document versions only) and then email them to your therapist before your first appointment, or print out the forms, fill them out by hand and bring them with you on your first appointment. Please note that the Psychotherapist-Patient Services Agreement form MUST be printed out, signed, and brought with you.

You also have the option of arriving for your first appointment 30 minutes early to complete ALL this paper work in the office (including the services agreement).

  • Psychotherapist-Patient Services Agreement — PDF (must be printed and signed)
  • Client Information Form (For Private Pay Clients) — PDF
  • Client Information Form (For Medicare Clients) — PDF
  • Life History Questionnaire — PDF
  • Social Media Policy — PDF
  • Adult General Symptom Checklist — PDF 
  • Couples/Partner Forms
    • Couples Counseling Service Agreement — PDF (must be printed and signed)
    • Couples Questionnaire — PDF
    • Dyadic Adjustment Scale (DAS) — PDF
    • Informed Consent for Participants in Couples Therapy — PDF (must be printed and signed)
  • Therapy Collateral Agreement — PDF
  • Informed Consent for Intended Parents — PDF
  • Fertility Health History for Intended Parents — PDF

Couples Homework – to be completed for your first session: It is important that we do not ONLY focus on the hurtful/negative aspects of your relationship.

  1. Describe the relationship you would like to create.
  2. What do YOU need to do/change to become a more effective partner?
  3. How or why would this be difficult for you?
  4. How motivated are you to make that change?
  5. What is your level of motivation to work on your personal difficulties?
  6. If you know that you are breaking up, what do you need to do to split most effectively so that the least amount of wounding will take place?

Please read the following two articles before your first session:

4 Reasons Communication Won’t Save Your Marriage

How to Get the Most Benefit From Couples Therapy

Please feel free to contact us with any questions or concerns.


Contact Today

Practicing telepsychology, while in Arizona, under the authority of PSYPACT in the following states:

(602) 548-1444

Got Questions?
Send a Message!