Marriage Enrichment Intake Form

Marriage Enrichment Intake Information

*Please submit this form only after you have scheduled your first appointment. Thank you.

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Contact Information

Your Name *

Your E-mail *

Your Phone *

Address *

Partner's Name *

Partner's E-mail

Partner's Pone

Questionnaire

How long have you been married? *

How long were you in a relationship PRIOR to being married? *

Were either of you previously married? *

Did either of you bring children from a previous relationship into this marriage? *

Please briefly describe your family situation at the time of your marriage (i.e. how many children, ages, sexes, custody/visitation arrangements, etc)

Do you have children together? *

Please indicate how many children you have and their ages/sexes

What is your current living situation? *

How long have you been living separately?

Do you practice a religion in the home? *

Please briefly describe (i.e. which religion(s) are practiced, by whom, etc)

Have either of you sought counseling in the PAST? *

Are either of you CURRENTLY in counseling? *

Counselor Name(s) & Contact Information

Please briefly describe your current relationship *

Please list any specific concerns

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