DEEPER Couples Retreat
Participant Intake Form
Name
*
First Name
Last Name
Partner Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
*
First Name
Last Name
Emergency Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Relationship Information
Length of Relationship
*
Are you currently married?
*
Yes
No
Current Relationship Challenges | Please check any areas that currently impact your relationship:
*
Communication difficulties
Conflict resolution
Trust concerns
Emotional disconnection
Stress management
Parenting challenges
Intimacy concerns
Other
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Safety Screening
To ensure the retreat is an appropriate setting for all couples, please answer the following:
Have there been any incidents of physical violence in the relationship within the past 12 months?
*
Yes
No
If yes, please briefly explain:
*
Do either partner currently feel unsafe in the relationship?
*
Yes
No
Are either of you currently receiving therapy?
*
Yes
No
If yes, provider name (optional):
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Medical / Accessibility Needs
Do you have any medical conditions or accessibility needs we should be aware of?
*
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Signature
Signature
Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Should be Empty: