Relationship Consulting Intake Form
Thank you for your interest in Dr. Zhana's Relationship Consulting. I know this is not an easy step to take.

Please complete this short intake form before our initial call so I can get to know you a little bit.
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Email *
What's your name (or the name you'd like me to use for you)?
Where are you located?
How did you find me?
Tell me a little about yourself and your partner/s. (Provide as much info as you think is relevant about your demographics, personal background, and relationship situation.)
Why are you currently seeking my assistance? What are you struggling with that I could help with? (Provide as much info as you think is relevant.)
How long has this issue been going on for? Have you done anything so far to try and address it?
Do you have an individual and/or a couples therapist, or any other mental health professionals supporting you and/or your partner/s? How long have you been working with them and are you satisfied with them?
Anything else I should know about you or your life circumstances that can help me understand your situation better?
Are you interested in the consulting package as an individual, a couple, or a larger relational unit (eg. throuple, quad, etc)?
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Are you able to commit to a minimum of 3 months of working together? 
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Can you afford a minimum of $5,000 (USD) per month for individuals/ $7,000 (USD) for couples for the duration of our work together? 
Clear selection
Thank you for filling out this questionnaire. I'll be in touch shortly.
A copy of your responses will be emailed to the address you provided.
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