Client Intake Form

Name *

First Name

Last Name

Phone *

(###)

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Referred to by:

Friend

Instagram

Facebook

Google Search

Other

Birthday

MM

DD

YYYY

Date of separation if applicable:

MM

DD

YYYY

What topics are you most interested in exploring? *

Select all that apply

Setting and enforcing boundaries

Setting realistic expectations

Managing big emotions that come with divorce (i.e. resentment, anger, shame, sadness)

Self-care and self-improvement

Communication

Documentation

Creating a parenting plan

Co-parenting and parallel parenting

Supporting my child(ren) through divorce

Finances

Preparing for mediation and/or court

Identifying red flags and learning how to avoid them in the future

Understanding toxic behavior tactics like manipulation, coercive control, gaslighting, blame shifting

Dating and designing an ideal relationship

Reaching acceptance