Surrogate Partner Therapy Intake Form

Personal Info

First Name

Last Name

Pronouns

Date of Birth (MM/DD/YYYY)

Occupation

Contact Info

Mobile Phone

Home Phone

Work Phone

Address

City

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Your talk therapist

Because Surrogate Partner Therapy requires the full, ongoing participation of a talk therapist, you must have an established relationship with a therapist before starting to see me.

Therapist's name

Therapist's phone number

Therapist's email address

What kind of therapist are you seeing?

Marriage and Family Therapist

Sex Therapist

Somatic Therapist

Internal Family Systems Therapist

Psychiatrist

Licensed Clinical Social Worker

Clinical Sexologist

Intimacy/ Relationship Coach

Other

How long have you been working with this therapist?

Have you discussed your interest in Surrogate Partner Therapy with this therapist?

Do I have permission to contact this therapist?

Your background

Please share with me any aspects of your identity that are important to you, such as race, ethnicity, class, physical ability, gender, sexuality, religion/ spirituality, etc.

Are you currently partnered? Please remember that Surrogate Partner Therapy is intended to prepare clients for future relationships. I will only accept partnered clients who have already attempted couples therapy.

What are the challenges or issues you would like to address in Surrogate Partner Therapy?

Have you been discussing these challenges with your talk therapist?

Do you have specific goals that you would like to reach?

How did you first hear about Surrogate Partner Therapy?

How did you find me?

Please select your preferred schedule

Regular sessions: meeting every other week for 2 hours/ session

An intensive in Oakland, California: meeting every day for 5-8 days, 4 hours/ day

An intensive in your hometown: meeting every day for 5-8 days, 4 hours/ day (please be aware that you would need to arrange my travel and accommodations)

Fees

My standard rate is $200/hr. I do have a limited number of sliding scale spots. If you would like to be added to my sliding scale waitlist, please give me some information about your situation and why sliding scale will be necessary for you.

Anything else you would like me to know

Is there anything else you would like me to know about you?