Complete the following forms, print them out, and bring them to your first session.
Client Intake Form
Confidentiality & Cancellation Policy Forms

For couples, please also complete:
Couple's Therapy Agreement


Pre-Therapy Forms

Couple Screening Form -
This form helps screen couples for the appropriateness of therapy and for the approach in therapy

Couple Satisfaction Survey -
This form rates the level of satisfaction in various parts of a couples life

Individual Problem Checklist -
This form is a survey of individual symptoms and problems.


Couple Therapy Forms

When We Are Not Getting Along: My Feelings, Thoughts, and Behaviors Checklist -
This is a survey of a partner's feelings, thoughts and behaviors when the couple is not getting alone.

Understanding Your Negative Cycle -
This form helps partners identify their reaction patterns and negative cycles of interactions


For Insurance Billing
After your first session, if you want me to help you bill your insurance company for sessions:
Karrie Guariglia, the billing service, can verify insurance coverage after your first visit.
Copy the information below to an email message, filling in the answers to each question, then email Karrie directly with this information.
or call at the number listed below.

Provider's Name: A. Susan Brenner


- What is your name?


- Are you male or female?


- What is your address (street address, city, state, zip code)?


- What is your Phone number?


- What is your Social Security #?


- Your date of birth?


- Your email address?


- What is the name of the policy holder?


- Which insurance company is the policy with?


- ID # of the policy?


- Date of birth of the policy holder?



Thank you!


After your first session, you may email your answers to Karrie at kmguariglia@comcast.net or call her with the information, please call 410-861-6030.




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