New Client intake formThank you for taking a few minutes to answer these questions: 1. PARTNER 1: Personal Information: Name * First Name Last Name Email * Phone * (###) ### #### Birthday Preferred Gender Pronouns: she/her he/him they/them other (space provided below) prefer not to answer If you answered 'other' please provide your gender pronouns below: 2. Background & Motivation: What brings you to Relationship sessions? What are your hopes and goals? What are your strengths and challenges in the relationship? What resources do you have to support your well-being? On a scale of 1-10, how would you rate your stress? (1 is lowest, 10 is highest) 3. Additional Information: Is there anything else you would like me to know about you that I did not ask? Do you have any questions for me? 1. PARTNER 2: Personal information: Name * First Name Last Name Email Birthday Preferred Gender Pronouns: they/them she/her he/him other If you answered 'other' please provide your gender pronouns below: 2. Background & Motivation: What brings you to Relationship sessions? What are your hopes and goals? What are your strengths and challenges in the relationship? What resources do you have to support your well-being? On a scale of 1-10, how would you rate your stress? (1 is lowest, 10 is highest): 3. Additional Information: Is there anything else you would like me to know about you that I did not ask? Do you have any questions for me? 4. Policies & Liability: FOR IN PERSON ONLY: COVID-19 precautions: Masks are now optional for sessions. I will match you if you come in with a mask. Are there any other COVID precautions that would feel supportive? FOR IN PERSON ONLY--- Please Initial that you agree--COVID Precautions: I agree not to come in to the office if in the last 10 days I have experienced COVID-19 like symptoms of have been exposed to anyone who may have COVID like symptoms * Please Initial that you Agree-- Liability Waiver: I acknowledge that Relationship Sessions with Michelle Huber are not a substitution for psychotherapy or medical diagnosis. I take responsibility to let Michelle Huber know about any relevant mental health conditions and to honor my own limitations. I hereby release Michelle Huber from responsibility for my mental health. * Please initial that you agree-- Cancellation policy: There will be no charge if appointments are cancelled 24 hours in advance. Cancellations with 24 hours of the scheduled time will be charged the full fee. If you have a COVID exposure or there is inclement weather and you need to cancel with less than 24 hours notice, you will also not be charged. Arriving more than 15 minutes late to the appointment will be considered a no show- and a full fee will be charged * Thank you so much for taking the time to answer these questions, please update Michelle if there are any changes.
