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NSCG PEABODY
NSCG NORTH ANDOVER
North Shore Clinicians Group
Referral Form: Couples | North Andover
*Please fill out the fields below and click on the "Submit Appointment Request" button at the bottom of the page. Thank you!
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Email:
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Mobile Phone:
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First Name
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Last Name:
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DOB:
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Gender
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Health Insurance
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Policy Number:
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Subscriber / Subscriber DOB:
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Copay Amount:
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Previous Therapy
Currently engaged in therapy with another provider.
Not currently in therapy, but received services within the past 3 months.
Last received therapy services more than 3 months ago.
No prior therapy experience.
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Inpatient Psychiatric History
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At least one inpatient admission in the past 3 months.
At least one inpatient admission in the past year.
Three or more previous inpatient hospitalizations.
No history of inpatient psychiatric hospitalization.
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Current Medication(s) & Allergies
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History of Legal Issues
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Currently involved in restraining order proceedings.
Currently involved in child custody proceedings.
Currently involved in other court proceedings.
Therapy is court-mandated or required by probation/parole.
Seeking therapy for proof of psychological injury
History of impulse control or violent behavior.
No known legal involvement or concerns.
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Substance Use History
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Currently using substances.
Clean and sober for less than 3 days.
Clean and sober for less than 3 months.
Clean and sober between 3 and 12 months.
Clean and sober for more than one year.
No history of substance use or addiction.
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Trust & Safety
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There has been an affair or breach of trust
There are concerns about honesty or secrecy
I feel emotionally safe in this relationship
I feel physically safe in this relationship
Substance use is impacting safety
Anger issues are impacting safety
No safety concerns
Please choose one.
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Relationship Status
Married
Engaged
Cohabiting / Living together
Dating
Separated
Divorced
Other
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Length of Relationship
< 6 months
< 1 year
1–3 years
3–7 years
7–15 years
15+ years
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Children
No children
Trying to conceive / IVF
Expecting / Pregnant
One child
Two children
Three or more
Adult children out
Adult children @ home
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Presenting Concerns
Communication difficulties
Frequent conflict / arguments
Infidelity or loss of trust
Parenting or blended family stress
Intimacy or sexual dissatisfaction
Emotional distance / lack of connection
Financial stress or decision-making conflict
Major life transition (e.g., relocation, illness, retirement)
Other reason for seeking therapy
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Communication & Conflict Patterns
We communicate effectively most of the time
We avoid difficult conversations
Arguments escalate quickly
One of us tends to withdraw or shut down
We repeat the same arguments without resolution
There is verbal hostility during conflict
There is physical aggression or fear during conflict
We repair conflicts & quickly and move on
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Emotional Connection & Intimacy
We feel emotionally connected
We struggle to express affection or appreciation
One or both partners feel unseen or unheard
We experience emotional distance
We are satisfied with our sexual relationship
We are dissatisfied with our sexual relationship
Intimacy has decreased significantly over time
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Goals For Therapy
Improve communication
Rebuild trust / heal after infidelity
Strengthen emotional and physical intimacy
Develop better conflict-resolution skills
Explore separation or discernment counseling
Improve co-parenting collaboration
Increase mutual understanding and empathy
Clarify relationship goals and next steps
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Background & Context
Both partners have prior therapy experience
One or both partners have a personal history of trauma
Mental health concerns impact the relationship
Extended family or cultural expectations cause tension
Financial, work, or health stressors are affecting the relationship
Different parenting styles or values create conflict
Faith or spiritual differences contribute to tension
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Readiness & Motivation
Both partners are motivated for therapy
Only one partner is motivated for therapy
We both take responsibility for our part in conflicts
One partner tends to blame the other
We have strong outside support (family/friends)
We have limited or no outside support
We are open to learning new skills and perspectives
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Days:
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Please check the days that you are available for appointments. Thank you!
Times:
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Morning
Afternoon
After 3pm
After 5pm
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Detailed Availability:
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Telehealth/Video Sessions?
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Only interested in telehealth sessions.
I prefer telehealth sessions.
I prefer in-person sessions.
Only interested in in-person sessions.
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Briefly describe why you are seeking counseling at this time.
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Home
About Us
Meet our Team
FAQ
Request Appointment
NSCG PEABODY
NSCG NORTH ANDOVER
North Shore Clinicians Group
(978) 535-1608 ext 1
main@nscliniciansgroup.com
North Shore Clinicians Group LLC est. 2011
