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Couples Intake Form

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Couples Intake Form

WELL MINDS COUNSELING, PLLC

Tana Carpita, MSW, LICSW

2525 E. Arizona Biltmore Circle, Suite B220

Phoenix, Arizona 85016
(425) 588.9280

Name of Person Filling Out Intake Form

First

Last

Describe your relationship including nature and duration

Describe your living situation

Why are you presenting for couple’s counseling?

What are the strengths in your relationship?

What are the tensions and struggles in your relationship?

How would you describe your sex life?

Is there a history of affairs, betrayal or cheating (emotional, physical or other)

What significant life changes or stressors have you experienced recently?

How do you cope together with challenges, stressors, adversity?

What things do you enjoy doing together?

What do you hope to get out of counseling and how will you know if it has been helpful?

What features of counseling/qualities of counselor are important to you?

Is there anything else you feel is important?

Contact

Tana Carpita, MSW, LCSW
Well Minds Counseling, PLLC
(425) 588-9280
trcarpita@wellmindscounseling.com

Location

Well Minds Counseling, PLLC
2525 E. Arizona Biltmore
Circle, Suite B220
Phoenix, Arizona 85016

Disclosure

I am an independently licensed clinical social worker, practicing with other clinicians under the name The Biltmore Wellness Collective. Read Full Disclosure

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