GETTING STARTED FORM FOR PRE-MARITAL COUNSELING
THIS INFORMATION LEGALLY WILL BE KEPT COMPLETELY CONFIDENTIAL. THIS FORM WILL TAKE BETWEEN 7 TO 10 MINUTES TO COMPLETE.
Name
*
First Name
Last Name
Partner's Name
*
First Name
Last Name
Your Date of Birth
-
Month
-
Day
Year
Date
What are your preferred pronouns?
*
Occupation
Email
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ABOUT YOU AS A COUPLE
Length of Time in Relationship:
*
What do you hope to accomplish through pre-marital counseling?
*
0/100
What are your biggest strengths as a couple?
*
0/100
What makes you want to marry your partner?
*
0/100
What are the areas of opportunity in your relationship?
*
Finances
Communication
Conflict Resolution
Intimacy
Fidelity
Please rate your current level of relationship happiness by circling the number that corresponds with your current feelings about the relationship.
*
Extremely Unhappy
1
2
3
4
5
6
7
8
9
Extremely Happy
10
1 is Extremely Unhappy, 10 is Extremely Happy
Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does.
*
0/100
Have you received prior couples counseling related to any of the above areas?
*
Yes
No
If yes, when:
If yes, where:
If yes, by whom:
Length of treatment:
Areas of Opportunity Treated:
What was the outcome?
Very successful
Somewhat successful
Stayed the same
Somewhat worse
Much worse
Not Applicable
Have either you or your partner been in INDIVIDUAL counseling before?
*
Yes
No
If yes, give a brief summary of concerns that you addressed.
0/100
Do either you or your partner drink alcohol to intoxication or take drugs to intoxication?
*
Yes
No
If yes for either, who, how often and what drugs or alcohol?
Have either you or your partner struck, physically restrained, used violence against or injured the other person?
*
Yes
No
If yes for either, who, how often and what happened.
Has either of you threatened to separate as a result of the current relationship opportunities?
*
Yes
No
If yes, Who?
Me
Partner
Both of Us
Rank order the top three opportunities that you have in your relationship with your partner (1 being the most problematic):
*
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