Intake Forms

For individuals and couples, please fill out the following intake forms:

• For Abbey's clients, please only fill out Abbey's Intake Paperwork.
• For all others:
  1. Informed Consent (click your therapist's name)
     • Michael Ciaccio
       • Michael's Telehealth Informed Consent (for video counseling only)
     • Chris Ellman
     • Mark Martinez
     • Julie Nielsen
  2. Center for Healing Assessment
  3. Social History 

For couples, in addition to the above forms, please fill out the following:

• Experiences in Close Relationship
• Dyadic Adjustment Scale

These will give us a picture of where you are and help us develop a collaborative treatment plan.  

For men struggling with pornography: 

Click on the link below to fill out a 10-minute assessment that will help you see the extent of the problem.  You will then receive a score ranging on a continuum from 1-7 along with practical tips for moving forward.  You may enter your therapist's email address at the end of the assessment to have it sent to him/her.  This assessment was developed by Dr. Kevin Skinner.  http://www.assessingpornaddiction.com/