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Emotionally Focused Therapy (EFT)

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Couples & Family Therapy
Emotionally Focused Therapy (EFT)

Helps couples build emotional bonds.

Tiffany Burgess

By ACMEAdmin|2026-03-18T22:47:32+00:00April 29th, 2025|Comments Off on Tiffany Burgess

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Intake Form

Step 1 of 3 - Patient Details

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Are you currently experiencing thoughts of suicide?

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No

If you’re feeling overwhelmed or struggling with thoughts of suicide, please know that you are not alone. There are people who care about you and want to help. You can reach out to the Suicide & Crisis Lifeline by calling 988 or visiting 988lifeline.org for immediate support. If you are in an emergency, please call 911 or go to the nearest emergency room. Your life is important, and reaching out for help is a strong and courageous step.

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Patient Details

Patient First Name(Required)

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Patient Email(Required)

Date of Birth(Required)

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Referred By

Have You Been Court Ordered to Therapy??(Required)

Yes

No

Please Upload the Court Order

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Name of Parent or Legal Guardian(Required)

First Last

Is There a Custody Agreement?(Required)

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Please Upload the Custody Agreement

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Are Restrictions Specified for Either Parent in the Agreement?(Required)

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Explain Restrictions(Required)

Are custody Issues present?(Required)

Yes

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Briefly Explain Issues(Required)

Insurance Info

Do you have Insurance?

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Are You In Network?(Required)

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Have You Been Seen Yet?

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Benefits 1 of 2

Is Provider In Network?

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