Intensive Couples Therapy Application Form

Skip to content

Home
About
- Services
- Rates
- Location
Meet Our Therapists
Groups and Classes
Appointments
Contact

Facebook Twitter Google Pinterest Youtube Email

Phone: 801-341-1919

Home
About
- Services
- Rates
- Location
Meet Our Therapists
Groups and Classes
Appointments
Contact

Apply Here:

Intensive Couples Therapy with Dr. Dome - Application Form

Because not all applicants are good candidates for this type of therapy, this form is to help determine your eligibility. Should you not meet requirements, we will help you find the right therapy for your needs. You will hear back within one business day to your email and/or phone number entered below.

Spouse 1 Name
First Last
Spouse 2 Name
First Last
Email*

The best email to contact you. Please make sure that this email is confidential and only accessed by you and your partner.
Phone*
Please ensure that we can leave a voicemail and text this number to ensure prompt and confidential communication.
Basic Description of Need*
Please describe why you are seeking couples therapy at this time.
Are both of you willing to take off of work up to five, non-consecutive days in a month for this therapy?*
While much of the intensive therapy can be done around schedules, time off from daily schedules is helpful and even necessary.
- Yes
- No
Is there any significant abuse in the relationship?*
- Yes
- No
If the answer above is yes, please explain how you will ensure safety during intensive therapy.
Requirements*
Do you both agree to the following: -If there has been an affair(s) that the affair(s) is(are) over completely. -To not file for divorce or work towards divorce in any way during therapy, but commit to working solely on saving the marriage. -That there is no current active drug or alcohol addiction. -That both of you acknowledge your individual contributions to the problems in your marriage, and that both of you are willing to address individual issues as part of the process.
- Yes
- No
- Maybe - I have a question
If you have any questions or concerns regarding the above requirements, please clarify here.
Do you have any children or other people living in your home?*
- Yes
- No
If so, please provide age(s) and any other pertinent information about others living in the home.
If you have any other questions or information, please type it below.
Consent*
I agree to the privacy policy.
By completing this form, you consent to sharing your information with our intake staff and the therapist to whom you will be referred. This form is confidential and will only be read by authorized staff to ensure we match you with the best therapist for your needs. Please provide as much detail as you are comfortable with, knowing that your information will be kept private and secure by our HIPAA-compliant team.
CAPTCHA

Δ

Saratoga Springs Phone - 801-341-1919

Scroll To Top