Jackson Hole Counseling

Marriage Counseling & Family Therapy

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  • Staff
    • Laura Santomauro, LMFT
    • Charlotte DiPrisco, LPC
    • Grace Donohue, MFT
    • Jimmy Rosen, MFT
  • Services
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    • 4 Attachment Styles
    • Secure Attachment
    • Anxious Attachment (ambivalent)
    • Avoidant Attachment
    • Disorganized Attachment
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  • Individual Therapy
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Individual Intake

Individual Intake

We appreciate you taking the time to complete this online form prior to your first session. Please be sure to wait until form is sent before you close the page, otherwise the form may not be received. Thank you.
  • PERSONAL INFORMATION

  • PRESENTING PROBLEM

  • PERSONAL HISTORY

  • PERSONAL HISTORY - substance abuse/addictions

  • MM slash DD slash YYYY
  • PERSONAL HISTORY - sexual trauma

  • PERSONAL HISTORY - family violence

  • RELATIONSHIP HISTORY

  • PAYMENT AGREEMENT

  • Please include: 1. credit card number 2. expiration date 3. CVV 4. Zip Code
  • This field is for validation purposes and should be left unchanged.

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