Name
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First Name
Last Name
Email
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Best Contact Number
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(###)
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Will you both be attending?
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Yes
No
Still Unsure
Name of your spouse/partner? (I will use the general term "partner" on this form as some filling this out may only be in a dating/engaged relationship)
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How long have you been dating or married?
Have either of you been married previously to this relationship?
No, neither of us have been married previously.
Yes, I've been married before but my partner has not.
Yes, my partner has been married before but I have not.
Yes, we have both been married previously.
Please share about your level of involvement in a local church community:
One or both of us are on staff or very involved at a ministry level within our church.
We are both actively involved in attending a local church.
I regularly attend church but my partner does not.
My partner regularly attends church but I do not.
Neither of us attend church anywhere at this time.
Option Two
Which best describes the personal faith/beliefs for you and your partner:
We both are Christians and have a close, personal relationship with the Lord.
We both identify as Christians, but neither of us really have developed a personal relationship with the Lord.
I am a Christian, my partner is not.
My partner is a Christian, I am not.
Neither of us are Christians.
Are you both in agreement and on board with pursuing couples counseling?
Yes, we are both on board with couples counseling.
I am for couples counseling, my partner is resistant/hesitant to coming.
I am for couples counseling, my partner is not thrilled about the idea but they're willing to come.
My partner is for couples counseling, I am not and fell resistant/hesitant to coming.
My partner is for couples counseling, I am not thrilled about the idea but am willing to come.
Please rate the accuracy of the following statement: my relationship with my significant other is healthy.
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Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Have any physical and/or emotional affairs taken place, at any time in your relationship, by either of you? If yes, please explain by whom, when, and duration of the affair.
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Check any of the following types of control happening (not a one time occurrence but ongoing patterns):
There's no issues with power, control, or abuse in our relationship.
Emotional control (invalidating feelings, silent treatment, threats, guilt to manipulate, blame for everything, deny affection, wake other up from sleep, etc..)
Financial control (limit access to accounts, must know every penny spent, must ask for money, creating debt, make all financial decisions, etc..)
Pets and property control (hurting pets, destroying property, punching walls, slamming doors, etc...)
Physical control (slap, hit, punch, bite, kick, restrain, choke, spit on, driving fast/reckless, lock out of the house, block exits, use an object rather than hands to cause harm, etc...)
Psychological control (say things then later deny it, intimidate with gestures/words, blame shifting, minimizing, threatening suicide, displaying weapons, false remorse, fake empathy, etc...)
Sexual control (forcing sex, sexual put downs, criticizing body, use of pornography, have or threaten to have an affair, sexually harming others, etc...)
Spiritual control (use scripture to excuse behaviors, twist scripture to gain power, isolate from faith community, put beliefs down, etc...)
Verbal control (sarcasm to put down, yelling, swearing, shaming, insults, condescending, name calling, cutting off in conversation, etc...)
If you checked any of the boxes above, please explain.
Have you or your partner battled addictions in the past or present?
Neither of us have battled addictions in the past or present.
I have battled addictions one year or longer in the past.
I currently battle an addiction(s)
My partner has battled addictions on year or longer in the past.
My partner currently battles addiction(s)
Please describe the specific addictions, if indicated above:
Use the space below to share your main reasons for seeking counseling at this time.
Please check any/ all preferences for scheduling the initial intake. (Please Note: I typically ask that only the parent(s) or guardian(s) come to the initial intake)
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Monday
Tuesday
Wednesday
Thursday
Friday
Any additional comments/questions?