Please fill out this form prior to the appointment Web Site Dr. Feldman is offering therapy by phone or video call while we are asked to stay at home. Name * Address (include city, zip) * Your Age * Email * Phone Number * Employment/ position or indicate if stay at home parent * How did you learn about my practice? * Do you have children? If so what age(s) * Briefly describe your reasons for seeking couples therapy * What do you hope to achieve through couple’s counseling * Are you currently taking any medications for psychological purposes? Please indicate. Have you engaged in psychotherapy or couples therapy before? If so when? Briefly describe your experience. Partner's Information Partners Name * Partners Age * How long have you been together? * Partners Occupation * Phone Number * Email *