Laura Santomauro, L.M.F.T.
350 East Broadway, Jackson WY 83001 • (307) 690-2153
Marriage Counseling & Family Therapy

INITIAL INTAKE

Initial Intake

Please take a moment to complete & submit the following information. PLEASE NOTE, if you are scheduled for couple's counseling, EACH PARTNER must complete & submit an intake. Should we NOT receive the information from both partners prior to your first appointment, we will take the time to complete the intake in office during your scheduled time.
  • PERSONAL INFORMATION

  • PRESENTING PROBLEM

  • PERSONAL HISTORY

  • PERSONAL HISTORY - substance abuse/addictions

  • PERSONAL HISTORY - sexual trauma

  • PERSONAL HISTORY - family violence

  • RELATIONSHIP HISTORY

  • This field is for validation purposes and should be left unchanged.
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