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*
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*
First Last
Date*
MM slash DD slash YYYY
Signature*
Client Name*
First Last
Date*
MM slash DD slash YYYY
Signature*