INTAKE FORM


Please complete the entire form after you have scheduled an appointment with me. Otherwise, please use the Contact page.

If you are single, please disregard the couple-related questions.

If you are a couple, each person should complete the entire form separately.

ALL questions are REQUIRED. If the question does not apply to you, simply put N/A or similar in the box. The fields cannot be empty.

YOUR INFORMATION
SPOUSE'S INFORMATION
YOUR FAMILY OF ORIGIN
THERAPY
Please provide a list of therapists you are currently seeing (if any). For each, include their role, and whether Roseanna has your permission to contact him or her if need be.
Please provide a description of current problems and issues to be addressed.
HEALTH CHECKLIST
Check all that apply to each family member and yourself.
ADDITIONAL INFORMATION
I would like each of you attending the session to submit a brief summary to me giving background information and your desired outcomes of the session. Please limit your responses to a single page. You may provide this summary in the box below or email your response to [email protected] (Do not send an email until AFTER you have clicked on the SUBMIT button below or your responses will be erased).