Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Phone
*
(###)
###
####
Is this your home, work, or mobile number?
*
Please select
Home
Work
Mobile
Can we leave messages at this number?
*
Email Address
What is your preferred method of contact?
*
Any
Phone
Email
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Do you or anyone coming to sessions with you have mobility issues which would make it challenging to access our office, which is up a flight of stairs?
*
Yes
No
If "Yes", please provide a brief description below.
What concerns are you seeking couple's therapy for?
*
Approximately, when did these concerns begin? How long have you been experiencing these concerns?
*
Has violence ever been a concern in your relationship?
*
Please select
Yes
No
Is alcohol/drug use currently a concern in your relationship (for you or your partner)?
*
Please select
Yes
No
Have you ever worked with any other helping professionals related to these concerns?
*
Please select
Yes
No
If "Yes", when?
If you're working with multiple helping professionals, please select the most recent.
If "Yes", what other helping professionals have you worked with related to these concerns?
Please check all that apply
If "Other", please provide a brief description below.
Is there anything else you think we should know or would like to share with us?
What days are you available for appointments?
*
Please check all that apply
What times are you available for appointments?
*
Please check all that apply
How do you wish to receive appointment reminders?
*
Reminders are sent 48 hours before your scheduled appointment
How did you find out about the Durham Couples' Clinic?
*
Please select
New Roots Therapy Website
Google Search
Therapist listing site (e.g., Psychology Today, Theravive, GoodTherapy.org)
Helping Professional (e.g., doctor, other therapist, etc.)
Family/Friend
Other
If "Other", please provide a brief description below.
*
A credit card number is required to reserve appointment times. We kindly ask that you have a credit card ready when we contact you to reserve your appointment.
*
