New Couples Counseling Questionnaire

Integrated Therapy Services NW

If this is an emergency, please call 911 or contact the Pierce County Crisis Line at 1-800-576-7764, the Kitsap County Crisis Line at 1-360-479-3033, or the National Suicide Hotline at 1-800-784-2433. If you have any questions, please call or email our office at 253-460-7248 or info@integratedtherapynw.com.

Contact Information

This form is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional healthcare services including the giving of medical/ psychological advice. No provider-patient relationship is formed by submitting this form. The use of this form is provided at the users own risk. The completion and submission of this form is not intended to be a substitution for individual medical or psychological advice, diagnosis or treatment. Users should not delay obtaining medical/psychological advice regarding any condition they have and should seek the assistance of their medical provider. Once the form is submitted, our office will email you within a few business days to confirm receipt and advise you of estimated availability to schedule with a provider.

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.

Client's Legal First and Last Name

Client's Date of Birth

Legal Sex

Male Female

Gender Identity

Client's Phone Number

Is it okay to leave voicemails?

Yes No

Email Address

For appointment reminders

Street Address

City

Zip Code

Partner's Information

Partner's Legal First and Last Name

Partner's Date of Birth

Partner's Legal Sex

Male Female

Partner's Gender Identity

Partner's Phone Number

Is it okay to leave voicemails?

Yes No

Partner's Email Address

For appointment reminders

Street Address

If different from above

City

Zip Code

How did you learn about ITS?

Do you personally know any ITS therapists/clients?

If yes, who?

Please explain the reason you are seeking counseling

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 6 months)?

Yes No

If yes, please explain

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

Yes No

If yes, please explain

Preferences

Therapist Preferences

Male Female No Preference

Other

Licensure Preference Please select one or more therapist type you are comfortable working with

Intern Level Therapist (Masters Candidate) - $100

Licensed Associated Therapist - $145

Licensed Therapist - $175

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.

Do you prefer Telehealth or in-person appointments?

Telehealth

Either

In-Person

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