Couples Therapy Enquiry Form

Please complete this form individually. Your responses are confidential and will not be shared with your partner. Both forms need to be received before I can respond to your enquiry.

First name

Last name

Phone number

How old are you this year?

Pronouns

What is your work/profession?

Name of partner/spouse

1. Primary Reasons for Seeking Therapy

In your own words, what is currently happening in your relationship that prompted you to seek couples therapy at this time?

2. Past Strategies & Outcomes

What have you both tried to address these challenges so far? What has or hasn't worked?

3. Goals for Change

What specific changes are you hoping to achieve – both in your relationship dynamic and in yourself?

4. Expectations of Therapy

How are you hoping I can best help or guide the two of you in our therapeutic work together?

5. Seeking Support

Whose initiative was it to seek couples therapy, and how does your partner feel about attending?

6. Safety Screening

To ensure I can provide a safe and effective therapeutic space for both of you, please share if any of the following apply:

Physical Safety: Are there any current or past concerns regarding physical aggression, property destruction, threats, intimidation, or feeling unsafe around your partner?

Substance Use or Legal Issues: Are active addiction, substance abuse, or ongoing legal matters impacting the relationship?

Mental Health History: Are there any relevant mental health conditions, current diagnoses, or medications I should be aware of?

7. Next Steps & Submission Window

Please ensure both your form and your partner’s form are submitted within 7 days of each other. You can send this form to your partner using this link here: https://www.lightingwaytherapy.com.sg/couples-therapy-enquiry-form

Enquiries are only reviewed when both forms are received. If it is not received within this timeframe, I will assume the enquiry is no longer active and will close the request.

I have read and agree to the Terms & Conditions for using the practice's services.