New Couples Counseling Questionnaire

Please correct the errors described below.

Contact Information

This form is to get established on the wait list for couples counseling services at Integrated Therapy Services NW. PLEASE NOTE: Estimated wait times vary depending on concerns, provider preferences, and availability. Once the form is submitted, our office will email you within 1-2 business days to confirm receipt.

Couples Counseling is CASH PAY ONLY. We do not bill insurance and cannot provide a superbill since there is no diagnosis or CPT code associated with the sessions.

For appointment reminders

Partner's Information

For appointment reminders
If different from above
If yes, who?

Current Concerns


Availability - What days or times generally work best for scheduling appointments? Our office hours are Monday - Friday, 8 AM - 7 PM.

Please note, afternoon and evening times are the most highly demanded and will likely result in a longer wait time.

In order to have a Telehealth appointment, the clients must be physically located in the state of Washington due to provider licensure.

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