Infidelity Coaching Intake Form

Today's Date*

Date

Wedding Anniversary*

Date

Husband's Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Email

example@example.com

Cell Phone

Religious Preference

example@example.com

Are you committed to restoring your marriage?

YesNo

Wife's Name

First NameLast Name

Address (If Different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Email

example@example.com

Cell Phone

Religious Preference

example@example.com

Are you committed to restoring your marriage?

YesNo

Referral Name (If Applicable)

First NameLast Name

Do you have kids? If yes, list the ages and sex.

Were you married in the Catholic Church?

YesNo

Have you received any previous counseling or therapy? If yes, please explain why you sought out help, how many sessions and when was the last session?

Are either one of you currently taking prescription medication?

YesNo

If yes, who and what?

Have either one of you ever been diagnosed or hospitalized with mental illness, personality disorder, anxiety disorder, etc.?

Has there been any previous incidences of infidelity in the marriage ?

YesNo

If yes, who and please provide details?

How long did it last? (e.g. one time, ongoing, please explain)

How was the infidelity discovered?

Who was involved in the infidelity that you are seeking help for now? How long ago?

How long did it last? (e.g. one time, ongoing, please explain)

How was the infidelity discovered?

Unfaithful - Have you ended the relationship?

YesNo

Have you both openly discussed the current infidelity?

YesNo

If yes, please explain how it went?

Unfaithful - What do you believe is the primary cause or factors contributing to the infidelity?

Betrayed - What do you believe is the primary cause or factors contributing to the infidelity?

How did the betrayed spouse feel after learning about the infidelity?

How did the unfaithful spouse feel after the infidelity was discovered?

Unfaithful - What is your current state of well-being?

Betrayed- What is your current state of well-being?

What is your current state of your marriage?

How is your ability to communicate with each other?

How is your sexual intimacy?

Has a STD test been done?

YesNo

If no, will the betrayed spouse request one?

YesNo

Betrayed, what is your level of trust in your spouse?

Unfaithful - What are your goals or objectives for seeking infidelity coaching?

Betrayed - What are your goals or objectives for seeking infidelity coaching?

Unfaithful - How do you envision the ideal outcome or resolution for your marriage following infidelity coaching?

Betrayed - How do you envision the ideal outcome or resolution for your marriage following infidelity coaching?

Unfaithful - Is there any other information or context you believe is important for us to know?

Betrayed - Is there any other information or context you believe is important for us to know?

How did you find out about Greg and Julie?

ADULT HOLD HARMLESS AGREEMENT

I voluntarily consent to be ministered to by Greg and Juilie Alexander (N-HIM Unlimited). I understand that some or all of the procedures used to give spiritual and emotional help through the use of the Healing Hearts Ministry may or may not be clinically demonstrated as guaranteeing either short-term or long-term results. I fully understand that the ministry I receive is NOT counseling in any form but rather prayer ministry. I accept this ministry fully and completely and do not hold anyone responsible for ANY outcome that may arise as a result of this ministry. I do not hold The Alexander House Apostolate, Inc. or its staff members responsible for any further or additional care that I may need in the future. I take full responsibility for my life, health and well-being now and in the days to come.

I am voluntarily accepting this offer of ministry and acknowledge that I understand that I am free to terminate my participation at any time for any reason. I understand that I must take full responsibility for any and all consequences for prematurely terminating any spiritual intervention done for or on my behalf. I also understand that once I leave this place of ministry, I accept full responsibility for any choices I make that may be detrimental or harmful to me.

I also accept full responsibility for all aftercare and follow-up ministry since this ministry opportunity is limited to this particular time frame and does not provide for any promise of future ministry.

I also fully understand that this ministry opportunity is being offered on a donation basis. I understand that this is not a professional counseling office nor are those providing ministry holding themselves out to be professional counselors but rather as prayer ministers. I accept this ministry opportunity as a gift and can freely give as I choose to support this cause but am under no obligation to pay for this service should I choose not to do so. If I choose to contribute any money to this ministry, it is to be viewed as a token of my appreciation and not as payment for service rendered.

Texas State law requires that, whenever a mandated reporter (clergy, school employees, medical providers, mental health professionals) has reasonable cause to suspect that a Minor has been subjected to abuse or neglect, or whenever a mandated reporter has observed a Minor being subjected to circumstances or conditions which would reasonably result in abuse or neglect, he or she must immediately report or cause a report to be made to the county Department of Human Services, the local police, or the local sheriff. Even when Diocesan Workers, Religious, and volunteers are not mandated reporters, they should report to law enforcement in accordance with ethical obligations.

My signature below indicates that I have read this agreement in full and agree to its terms.

*Your signature below indicates that the information you have provided above is truthful, and you agree with the Adult Hold Harmless Agreement.

Husband's Signature

Wife's Signature