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Marriage Counseling Forms

Complete the Patient Fusion online check-in first. You must complete the online check-in at least 48 hours before your appointment for the information to be received in time for your appointment. 

Then print out and complete these forms by selecting Policies, Benefits, Contract at the bottom of this page. Bring these forms with you to your first session along with identification (driver's license or government ID) and health insurance cards. 
  1. Only the primary insured client should complete the Patient Fusion check-in.
  2. After completing the Patient Fusion check-in print out and complete the Couples Intake Packet at the bottom of this page. It contains forms for both of you. 
  3. Each of you should fill out a Couples Counseling Intake Form. (Do not share the Couples Counseling Intake Form with each other. Hold onto your copy until your session, then give your form directly to Dr. Diak.) 
  4. Only the spouse/partner (not the primary insured client) should fill out the Psychotherapy Services Agreement For Collaterals. 
    1. On page 1 next to (client) print the name of the primary insured client. 
    2. On page 2 the spouse/partner (not the primary insured client) should sign and print their name.

Printing Help

Links to the forms are at the bottom of this page. Click on the form's name to open it directly, then print it out. Or click on the downward arrow to the right of the form's name to download it. Then open the form, and print it out. 

If the forms do not open automatically you may need to download and install the program Adobe Reader here. It is a free program. 

If the forms do not look properly formatted on your screen, try downloading the forms to your computer, and then opening them with Adobe Reader to print them.

If you prefer, you may request the forms to fill out at the time of your visit. Arrive 30 minutes before your appointment to allow sufficient time to complete the forms. 
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Couples Intake Packet May 2017.pdf
(1235k)
Frank Diak,
May 18, 2017, 9:32 AM
v.1