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Marriage Counseling Forms- Paper

This page is for new marriage/couples counseling clients who want to complete all paper forms, and do not want to fill out some of their forms online using Patient Fusion check-in. To complete some of the forms online check your email inbox for a separate email from Patient Fusion. 

Please print out and complete these forms prior to your appointment to make the best use of your session time.
  1. Print out the Couples Intake Forms Packet at the bottom of this page. 
  2. Only the primary insured client needs to fill out the Client History.
  3. Each of you should fill out a Couples Counseling Intake Form. 
  4. Do not share the Couples Counseling Intake Form with each other. 
  5. Each of you should hold onto your copy until your session. Give your form directly to Dr. Diak. 
  6. 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. 

Bring To Your Appointment

        7. The Completed Forms
        8. Driver's License or Government ID
        9. Health Insurance Cards  

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. 
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Frank Diak,
Jun 25, 2016, 9:31 PM