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Couples Informed Consent
Couples Informed Consent
Both parties should provide this consent, if a second form is needed please click the original link and the other party can submit their own form.
Please Select Your Therapist
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Please select your therapist from the drop down
Ahmed Adetola
Alicia Zymblosky
Allison Kleinman
Alysia Ardo
Amanda Leonard
Amanda Rickard
Ann Fischetti
Ardie Kissinger
Ashley Gross
Barbara Serino
Bethany Woznikaitis
Brittany Lippert
Brooke McDonnell
Carrie Greene
Catherine Douglas
Chelsea Collins
Corinne Crum
Danielle Ross
David Falbo
Les Smith
Elise Klinger
Eleanor (Ellie) Harrison
Erica Senak
Jaclyn Froman
Jacob Herber
Jason Kowalski
Jeanne Decker
Jennifer Marzacco
Jennifer Weaver
Joanne Judge
Jodi Weiskerger
John Gibbons
John Kuna
Karlene Albrecht
Keith Ripley
Kelly Borich
Kirstie Pysher
Linda Strain
Lori Kishel
Marci Duffy
Michele Elliott
Nadine Henzes-Gowarty
Patricia Arcaro-Krenitsky
Phil Zuckerman
Rebekah Howell
Renee Trombley
Roya Fahmy
Sara Grier
Sinead O'Hare
Stephanie Fischer
Sylvie Acoulon
Tammy Gregorowicz
Theresa Schirg
Tony Black
Tracy Fromm
Vanessa Durland
Other / not listed / I Don't see them listed
Jason Kuna
William (Bill) Rusen
Couple's therapy starts with an assessment of the relationship past and present. We understand that information discussed in couple's therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving the partners. We agree not to request or subpoena the therapist we are/will see below to testify for or against either party or to provide records in a legal or civil action.
By entering into couple's therapy, we accept that we both understand that working toward change may involve experiencing difficult and intense feelings, some of which may be painful in order to reach our goals. We accept that such changes can have both negative and positive effects and agree to clarify and evaluate potential effects of changes before we undertake them.
If the relationship dissolves and either or both of you wish to re-engage with the therapist below for individual counseling, the decision with whom the therapist below continues working is at his / her discretion. In some circumstances a referral for one or both may be made.
Client Name
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First
Last
Date
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Signature
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Client Name
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First
Last
Date
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MM slash DD slash YYYY
Signature
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