Intake form - couples

This form can only be completed by the individuals who attend the appointment, and cannot be completed on behalf of another individual.

After submitting this form you may be contacted to confirm additional details as well as a day and time for your first appointment.

General Information

How did you come to choose Wise Psychology?

If other source for choosing Wise Psychology, type it below:

If a GP referred you, tell us which one so we can say thank you:

Who have you been referred to? *

Primary attendee | Contact information

The primary attendee will be the main point of contact for coordinating appointments, payments and other administrative and clinical matters. To avoid uncertainty, the primary attendee is responsible for costs.

Title *

First name *

Surname *

Preferred name

Pronouns *

Gender *

Gender Other

Email Address *

Mobile phone *

Primary attendee | Emergency Contact Information

By providing these details, you consent to the named individual being contacted in the event of an emergency or when contact is deemed clinically necessary by your practitioner, and you cannot be contacted directly.

You acknowledge contact with this individual may result in disclosure of the existence of the treatment relationship.

The emergency contact for couples appointments can not be an attendee of the session.

i.e. the primary and additional attendees can not be the emergency contact for each other.

Emergency contact title *

Emergency contact first name *

Emergency contact surname *

Emergency contact’s relationship to you. *

Emergency contact email address

Emergency contact mobile phone *

Primary attendee consent

I the primary attendee confirm that the information I have provided is true, complete, and accurate *

I, the primary attendee, confirm that I am the person named on this form *

I, the primary attendee, confirm that I have read, understand, and consent to the Privacy Policy and Terms of Use for Wise Psychology *

I give consent to receive from Wise Psychology, infrequent promotional information about services offered and other related communications.

Primary attendee signature: *

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Date: *

Additional attendee | Contact information

The additional attendee will be the secondary point of contact for coordinating appointments, payments and other administrative and clinical matters. To avoid uncertainty, the primary attendee is responsible for costs.

Additional attendee title *

Additional attendee first name *

Additional attendee surname *

Additional attendee preferred name

Additional attendee pronouns *

Additional attendee gender *

Additional attendee gender other

Additional attendee email address *

Additional attendee mobile phone *

Additional attendee | Emergency Contact Information

You acknowledge contact with this individual may result in disclosure of the existence of the treatment relationship.

The emergency contact for couples appointments can not be an attendee of the session.

i.e. the primary and additional attendees can not be the emergency contact for each other.

Additional attendee emergency contact title *

Additional attendee emergency contact first name *

Additional attendee emergency contact surname *

Additional attendees emergency contact’s relationship. *

Additional attendees emergency contact email address

Additional attendees emergency contact mobile phone *

Additional attendee consent

I, the additional attendee, confirm that the information I have provided is true, complete, and accurate *

I, the additional attendee, confirm that I am the person named on this form *

I, the additional attendee, confirm that I have read, understand, and consent to the Privacy Policy and Terms of Use for Wise Psychology *

I give consent to receive from Wise Psychology infrequent promotional information about services offered and other related communications.

Additional attendee signature: *

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Date: *