Seattle Therapy Alliance

Couples Therapy Confidential Patient Intake Form

Couples Patient Information

Date______

Patient Information

Full Legal Names Partner #1 ______

Partner #2______

Preferred nickname Partner #1______

Partner #2 ______

Date of Birth Partner #1______

Date of Birth Partner #2 ______

GenderIdentification Partner #1______

GenderIdentification Partner #2______

Sexual Orientation Partner #1 ______

Sexual Orientation Partner #2 ______

Race/Ethniticy Partner #1______

Race/Ethniticy Partner #2______

Any other identifying information you would like us to know?______

______

Would you prefer to work with a therapist of color? ______

Mailing Address ______

Email Address Partner #1 ______OK to email you here? Y N

Email Address Partner #2 ______OK to email you here? Y N

Phone # Partner #1 ______OK to call you here? Y N

OK to leave a message? Y N

Phone # Partner #2 ______OK to call you here? Y N

OK to leave a message? Y N

Emergency Contact Name ______Phone______

Relationship of Emergency Contact______

Statement of Need

Please provide a brief description of your reasons for seeking couples counseling at this time.

______

______

______

How have these concerns evolved over time?

______

______

______

What are your goals for our counseling work?

______

______

______

Please circle your current level of commitment, confidence and distress in your relationship:

Level of commitment / Level of confidence / Level of distress
1 2 3 4 5 / 1 2 3 4 5 / 1 2 3 4 5
Low High / Low High / Extremely Extremely
Unhappy Happy

Please check of any of the following struggles that pertain to your relationship:

Anxiety / Depression / Fears/Phobias / Eating Disorders
Sexual Problems / Suicidal Thoughts / Separation/Divorce / Relationships
Finances / Drug/Alcohol Use / Career Choices / Anger
Self-Control / Unhappiness / Insomnia / Religious Matters
Work/Stress / Health Problems / Cutting/Self-Mutilation / Thought Patterns

History of Care

Information of Personal Physician Name______Phone______

Are either of you currently under medical care? Y / N

If yes, then please explain

______

______

______

Are either of you currently taking prescribed medications? Y / N

If yes, then please explain.

______

______

______

List any psychiatric/mental health medications either of you have taken:

______

______

Have either of you been under the care of a psychiatrist, psychologist, or counselor? Y / N

If yes, please give the name and date of the therapy and briefly explain the nature of the problem that required attention.

______

______

______

Have either of you ever been hospitalized for a mental health condition? Y / N

If yes, please give the date and briefly explain the nature of the problem that required attention.

______

______

______

Have either of you ever been in a drug or alcohol treatment program? Y / N

If yes, please give the facility, length of time in treatment and outcome.

______

______

______

Do either of you currently drink alcohol? Y / N

How much? How often? ______

Do either of you currently use recreational drugs? Y / N

How often? What substances? ______

______

______

Do either of you feel you have a problem with either alcohol or drugs? Y / N

Have either of you ever attempted or considered suicide? Y / N

If yes, please provide some details.

______

______

______

Do either of you have practice cutting? Y / N

If yes, provide comments or thoughts

______

______

______

Recent weight gain or loss Y / N ______

Is there anything else you think your therapist should know about prior to our beginning your treatment?

Demonstration of Financial Need

STA provides low-cost therapy for clients who are unable to afford the customary fees for psychotherapy. For a limited time for all new couples clients,we are currently offering couples counseling, the same fees as individual on a sliding scale between $55-75. STA is unable to provide free services, and insurance will not be billed for sessions. See STA’s Disclosure Statement for more information.

Are you able to pay between $55-75 per session? Yes No

In the event STA provides you with a referral, do you have insurance? Y N

If yes, what is your insurance provider? ______

Schedule

Seattle Therapy Alliance has a number of counseling times available, and we do our best to offer clients an appointment time within their availability. Please indicate below the days and times you are available to see a counselor.

Time / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
8am
9am
10a
11:30am
12:30pm
1:30pm
2:30pm
3:30pm
4:30pm
6pm
7pm
8pm

What would your top two ideal appointment times be?

How certain are you, on a scale of 1 to 10, that you will be able to commit to weekly couples therapy for a period of up to one year? (1 being completely uncertain and 10 being completely certain)

1 2 3 4 5 6 7 8 9 10

**Please be aware that if you are not able to protect the time that is agreed upon, we will not be able to guarantee you another counseling spot.

Please return this form by email to:

Or by mail to:

Seattle Therapy Alliance

Attn: Grace Rock

200 1st Avenue W

Seattle, WA 98119

Thank you for submitting your application.