IVY KWONG, LMFT
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COUPLES FORM
Please complete this form thoroughly and I will make every effort to get back to you within 48 hours. A complimentary thirty-minute phone consultation to explore the possibility of working together may be
scheduled here
.
*
Indicates required field
Your Name
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Your Partner's Name
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E-mail
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Confirm E-mail
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Phone Number
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Current Location (City)
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Which of the following are you interested in? Check all that apply.
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Couples Therapy
Couples Intensive
Online Couples Courses
Couples Retreats & Workshops
What is your level of experience with couples therapy?
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No experience
A little experience
Somewhat experienced
Very experienced
Which areas would you like support with? (check all that apply)
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Communication
Managing Conflict
Trust
Sex
Neglect
Affair/Infidelity
Betrayal
Physical Abuse
Emotional Abuse
Finances
Compatibility
Premarital Counseling
Parenting
Separation
Divorce
Addiction
Life Transition
Other (describe below)
Which three of the above areas would you like to address first?
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What is the single greatest struggle you have right now?
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Describe your dream outcome from our work together.
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How would you like to connect? (check all that apply)
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Video chat (i.e. Skype, Google Chat)
Phone
In person
Is there any additional information that you would like to share with me at this time?
*
Submit
Home
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Work with Me
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