Please complete this packet and bring it with you to your first session. Bonus points if you send it to me to review prior to our first session. Send me this packet electronically via email at melissa@msfamilytherapy.com For your privacy, it is best to send this information encrypted (every email platform gives an option to send email encrypted for free).

This form is for couples beginning couples therapy. Each partner needs to complete this form and send it back to me prior to the first session.

**Please note that you also need to complete the entire Intake Packet as well as the couples form if you are doing couples therapy.

Signing this form gives me permission to talk about relevant clinical information with an individual that you designate. I can't coordinate care for you until I receive this signed document. Sending this via encrypted email is the best way to ensure your privacy.

Any minor under the age of 18 must complete this form in order to be seen for therapy.