Couples Group Sign-Up

PLEASE NOTE: Each module is $750 out of pocket, no insurance will be billed.

Payment due in full prior to first class.

This form is to become established on the list to participate in the Couples Group at Integrated Therapy Services NW. Once the form is submitted, our office will contact you within 5-7 business days.

Couples Group is designed to provide couples with a supportive group environment where they can develop better communication skills, address conflicts, and strengthen their relationships

The group runs Mondays from 6:00 PM - 8:00 PM.

The group is one, 5 week module (with an option for a second module), where each meeting is 2 hours, once per week.

Partner 1: Legal First and Last Name

Partner 1: Date of Birth

Legal Sex

Female Male

Gender Identity

Partner 1: Phone number

Is it ok to leave voicemails?

Yes No

Partner 1: Email address

Street Address

City

Zip Code

Partner 2: Legal First and Last Name

Partner 2: Date of Birth

Legal Sex

Female Male

Gender Identity

Partner 2: Phone number

Is it ok to leave voicemails?

Yes No

Partner 2: Email address

Street Address

City

Zip Code

How did you learn about Couples Group?

Do you personally know any ITS therapists/clients?

If yes, who?

Please explain the reason you are seeking group

Current Concerns

Is anyone in your household currently pregnant or pregnant within the past 3 years?

Yes No

If yes, due/birth date

Are you currently experiencing domestic violence (within the past 12 months)?

Yes No

If yes, please explain

Is either partner experiencing suicidal ideation or thoughts of self harm?

Yes No

If yes, please explain

If yes to the previous question, are you seeing an individual therapist?

Yes No N/A

Your information will be encrypted.