Couple's Pre-Appointment Questionnaire

Please correct the errors described below.

Emergency Assistance

If this is an emergency, call: 269-381-4957

First Name

Last Name

Email Address

Why are you seeking couples counseling at this time?

Are there any topics that you do NOT want to talk about during our first session?

Please click the areas that are of concern to you.

Arguing

Criticism

Shutting Down

Hurtful words

Infidelity

Having Fun

Closeness

Alcohol Use

Romance

Scorn

Depression

Busyness

Hitting

Anxiety

Infertility

In-Laws

Drug Use

Ex's

Porn Use

Politics

Life Goals

Communication

Chores

Sexual Orientation

Physical Illness

Religious Conflict

Values

Money

Parenting

Sexual Desire

Please describe any other concern that you have about your partner:

Your information will be encrypted.

Emergency Assistance

If this is an emergency, call: 269-381-4957

Charles D. Thomas

Nationally Certified Counselor

Charles D. Thomas has been practicing for more than 20 years, specializing in men's issues and couples therapy.

269-718-3366
www.thedeerfield.com
5900 Portage Road, Portage, MI, 49002

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