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I look forward to working with you and your partner. If you have already booked an appointment with me please complete the forms and deposit below. 

Danika Lowry, LCSW intensive couples therapist with The Cottage at 933 in South Bend, Indiana

Intake Forms

Please complete the forms below. The sign and date forms should be returned within three business days (along with deposit). The personal history form should be returned seven days prior to your scheduled session. Each partner must complete all forms.

Danika will review the personal history forms and make reference to them during your session. Do not include anything that cannot be referred to in session. PLEASE TYPE ANSWERS

Return forms using one of the following methods:

Fax: 574-217-4589 

Mail: 51728 IN 933 South Bend, IN 46637

E-mail is not HIPAA compliant. The use of email to submit forms is at your own discretion.


A 50% deposit is required within three business days of booking an Accelerated Couples Therapy session. Failure to provide a deposit may result in forfeiture of date/time selected. Please read the fee policy carefully. While extenuating circumstances are taken into consideration, there is a strict cancellation policy for one day and two day sessions. 

As an alternative to paying online you may also mail a check to 51728 IN 933 South Bend, IN 46637

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