Marriage/Couple Counseling Contact Form
(PLEASE CHECK ALL THAT APPLY TO YOUR CURRENT SITUATION)
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Name: *
Spouse/Significant Other's Name: *
Are Both of You Willing/Wanting to Participate in Counseling? *
Contact Number: *
Contact Email: *
Is Your Relationship Experiencing Any of the Following:  (Please Answer All Areas of Concern) *
Yes
No
Alcohol Abuse
Anger
Anxiety
Blame
Blended Family Problems
Communication
Dependency
Depression Due to Relationship Problems
Depression Independent of Relationship
Disillusionment With Relationship
Eating Disorders
Financial Conflict
Infidelity
Internet Sexual Use
Intimate Partner Violence - Terrorism
Intimate Partner Violence - Situational
Intolerance
Jealousy
Job Stress
Life-Changing Events
Loss of Love/Affection
Midlife Transition Problems
Only (1) Partner Willing To Attend Therapy
Parenting Conflicts - Adolescents
Parenting Conflicts - Children
Personality Differences
Psychological Abuse
Recreational Activities Dispute
Religious/Spirituality Differences
Retirement
Separation and Divorce
Sexual Abuse
Sexual Dysfunction
Transition to Parenthood Strains
Work/Home Role Strain
What Health Plan Do You Both Participate In? *
If Other or Multiple Health Plans, Please List Below:
What is the Preferred Availability For You Both? (PLEASE LIST DAYS & TIMES) *
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