ASL Pre-Screening Interview ⋆ Couples Counseling & Professional Training Associates

The Art & Science of Love Pre-Screening Interview Form

Each attendee must fill out this form individually. This screening is confidential and part of the registration process for all participants. Please contact us if you have any questions.

Name
First Last
Phone
How did you hear about this workshop?
By whom were you referred?
How do you and your partner feel about coming to the workshop?*
Do you have any concerns or special needs? Please list them below.
In an effort to make sure this is a safe and positive experience for everyone, we do ask some sensitive questions. These questions are required for the screening. If you answer YES to these questions, we will require additional information and someone from our office will contact you.
Has there ever been any violence between you and your partner?*
- Yes
- No
- Unsure/Don't Know
Are either you or your partner in treatment for any serious mental health issue (e.g. Bipolar or Depression disorders) or have there been any suicide attempts or ideation? (choose all that apply)*
- I am in treatment for serious mental health issues
- My partner is in treatment for serious mental health issues
- I have had suicide attempts or ideation
- My partner has had suicide attempts or ideation
- None of the above
If needed, we may request permission to speak with your therapist/doctor. We will contact you for more information.

The Art & Science of Love Pre-Screening Interview Form

In an effort to make sure this is a safe and positive experience for everyone, we do ask some sensitive questions. These questions are required for the screening. If you answer YES to these questions, we will require additional information and someone from our office will contact you.

If needed, we may request permission to speak with your therapist/doctor. We will contact you for more information.