Couples Coaching Intake Form
Please complete this form to help us understand your goals and background for couples coaching.
Your Information
Please enter your personal details.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Occupation
Partner’s Information
Please enter your partner's details.
Partner's Full Name
*
First Name
Last Name
Partner's Email Address
*
example@example.com
Partner's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Partner's Age
*
Partner's Occupation
Relationship Details
Tell us about your relationship.
Relationship Status
*
Dating
Engaged
Married
Other
Length of Relationship (in years/months)
*
Are you currently living together?
*
Yes
No
What prompted you to reach out right now?
*
What are the top areas you’d like help with? (Select all that apply)
*
Communication
Conflict
Trust
Premarital Preparation
Faith/Spirituality
Stress
Intimacy
Other
What feels strongest in your relationship?
What feels most difficult right now?
Have either of you done individual or couples counseling before?
*
Yes
No
If yes, briefly explain:
If this process were successful, what would be different in your relationship 6 months from now?
Coaching Agreement & Consent
Please read and acknowledge the following terms before submitting your intake form.
Submit Intake Form
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