STOP! **NOT ACCEPTING NEW CLIENTS AT THIS TIME**
Street Address Line 2
State / Province
Postal / Zip Code
Step 2: Relationship Information
Now, let's talk about your relationship. Describe your relationship and needs.
Are you currently:
Is your partner in agreement that couples counseling is necessary in your relationship at this time?
Briefly describe your relationship (please note this is completely confidential):
What is the biggest challenge you face in your relationship?
If you are accepted as a new client, what are the three goals you desire to achieve in your relationship?
Why is it so important to you that your relationship is successful?
What do you feel will be the biggest benefit to obtaining couples therapy?
On a scale of 1 (lowest) to 10 (highest), how willing and able are you (and your partner) to invest the times, money, and resources into creating a healthy relationship?
Where would you like to be 6 months from now in your relationship?
Is there any additional information you would like to share with Kiaundra as she considers you and your partner for couples counseling?
Step 4: Submit Answers
Please make sure to review your answers before submitting this questionnaire.
We respect your privacy.
Your information will not be disclosed or shared.
Should be Empty:
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