Intake form - Couples Name (individual 1) * First Name Last Name Email * Address * Phone * (###) ### #### What services are you interested in? Individual Couples Preferred Date MM DD YYYY How did you hear about us? Instagram Google search Word of mouth Professional referral Other Next of kin/ Emergency Contact Name & number Reason for seeking psycho-sexology * Please briefly describe your reason for seeking sessions How long have these concerns been present? Have you previously attended therapy? Yes No Other involved professionals Medications If yes, please list what medications you are taking Expectation of therapy What would you most like to address within session? In submitting this intake form, you are required to confirm you have reviewed our policies and consent to them. Please review and ensure you accept the Policies of The New Normal Sexology. Consent Thank you! Name (individual 2) * First Name Last Name Email * Address * Phone * (###) ### #### What services are you interested in? Individual Couples Preferred Date MM DD YYYY How did you hear about us? Instagram Google search Word of mouth Professional referral Other Next of kin/ Emergency Contact Name & number Reason for seeking psycho-sexology * Please briefly describe your reason for seeking sessions How long have these concerns been present? Have you previously attended therapy? Yes No Other involved professionals Medications If yes, please list what medications you are taking Expectation of therapy What would you most like to address within session? In submitting this intake form, you are required to confirm you have reviewed our policies and consent to them. Please review and ensure you accept the Policies of The New Normal Sexology. Consent Thank you!