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COUNSELING |
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  Couples Counseling
  Premarital Counseling
  Sex Counseling
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  LGBTQ+ Therapy and Couples Counseling
  Couples Intensive
  Marriage Counseling Questions
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CORE RELATIONSHIP DESIRE QUIZ
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Search for:

COUNSELING |
- AREAS OF EXPERTISE
  Couples Counseling
  Premarital Counseling
  Sex Counseling
  Counseling for Open Relationships
  Individual Counseling
  Sliding Scale Therapy
  LGBTQ+ Therapy and Couples Counseling
  Couples Intensive
  Marriage Counseling Questions
LOCATIONS|
- California
  San Francisco
  East Bay (Berkeley, Oakland, El Cerrito )
  Los Angeles
  Marin and Santa Rosa
  Roseville
  Sacramento
  San Diego
  San Jose
  Palo Alto
  Walnut Creek
- Florida
  Ft. Lauderdale & Miami
WORKSHOPS |
COURSES |
BLOG |
ABOUT
CORE RELATIONSHIP DESIRE QUIZ
Get Help Now
Search for:

COUNSELING |
- AREAS OF EXPERTISE
  Couples Counseling
  Premarital Counseling
  Sex Counseling
  Counseling for Open Relationships
  Individual Counseling
  Sliding Scale Therapy
  LGBTQ+ Therapy and Couples Counseling
  Couples Intensive
  Marriage Counseling Questions
LOCATIONS|
- California
  San Francisco
  East Bay (Berkeley, Oakland, El Cerrito )
  Los Angeles
  Marin and Santa Rosa
  Roseville
  Sacramento
  San Diego
  San Jose
  Palo Alto
  Walnut Creek
- Florida
  Ft. Lauderdale & Miami
WORKSHOPS |
COURSES |
BLOG |
ABOUT
CORE RELATIONSHIP DESIRE QUIZ
Get Help Now

The Couples Center Couples Therapy Berkeley and East Bay

Sep 13, 19|

Complete Our Intake Form to Match the Right Relationship Therapist

First Name *

Last Name *

I identify as: *

Birth Year *

Phone Number *

Email Address *

Preferred Contact Method *

Partner's First Name *

Partner Identifies as: *

Partner's Birth Year *

Preferred location of sessions. *

What's the best time for a follow up consultation call? *

Best Day(s) and Time(s) For Sessions (may select more than one) *

Weekday Mornings (Before 12 Noon PDT)

Weekday Early Afternoon (12 pm - 4 pm PDT)

Weekday Evenings (After 4 pm PDT)

Weekend Mornings (Before 12 Noon PDT)

Weekend Afternoons (12 pm - 4 pm PDT)

Weekend Evenings (After 4 pm PDT)

Please Note Specific Times That Work For Sessions *

Do you prefer a straight or LGBTQ+ therapist? *

Our licensed therapists have 5+ years of experience. Our associate therapists have 2-5 years of experience and work on a sliding scale. Note: select only one option. Please see our fees below for more information. *

Senior Therapist ($250 per 50 min session, $370 per 75 min)

Licensed Therapist ($220 per 50 min session, $325 per 75 min)

Associate Therapist ($160 per 50 minute session, $235 per 75 min)

Either is fine, I want the therapist that is the best fit for me.

Please select the applicable reasons you are seeking therapy: *

Learn Communication Skills

Sex/Intimacy Counseling

Repeat Arguments/Verbal Disputes

Premarital Counseling

Family Issues/Parenting

Separation/Divorce

Change of Life/Major Decisions

Personal Growth/Happiness

Infidelity/Trust Issues

We're good, but we want to be great.

Other

Have arguments or fights ever become physical? (Individuals please select N/A? *

If comfortable, please describe how/when the fights escalated:

How long have you been together? *

Additional Comments and/or Requests

How did you hear about us? *

UTM Source

UTM Medium

UTM Campaign

UTM Content

UTM Term

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