CALL 229-339-3721

COUPLES INTAKE FORM

Please complete the SECURE on-line form below.

COUPLES INTAKE FORM

Relationship Status:

As you think about the primary reason that brings you here, how would you rate its frequency and your overall llbevel of concern at this point in time?

Have you received prior couples counseling related to any of the above problems?

What was the outcome(check one)?

Have either you or your partner been in individual counseling before?

Do either you or your partner drink alcohol to intoxication or take drugs to intoxication?

Have either you or your partner struck, physically restrained, used violence against or injured the other person?

4 + 4 =

tiftareapacs.com

Tiftarea Psychiatric and Counseling Services, LLC. | Office Address: 223 East 2nd Street Suite B Tifton, Georgia 31794
Phone: 229-339-3721 | Fax: 229-472-9151 | Mailing Address: Post Office Box 1613 Tifton, Georgia 31793
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