Couples Workshop Interest Questionnaire

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Thank you for your interest in our couples workshop! In order to streamline the process and be sure that this group is a good fit for your needs, please fill out this questionnaire. Thank you!

Email *

Contact Number *

Your name & your partner's name *

How long have you and your partner been together? *

Are you married? *

Yes

Other:

Do you live together? *

Yes

Other:

Have you or your partner ever felt unsafe due to any incidents of physical or sexual violence within the relationship? *

If yes, please share

What are the topics that are the most relevant to your relationship? *

Check any/all that apply

Trust Issues: Challenges with honesty, fidelity, or past betrayals.

Life Transitions: Struggling to adapt to major life changes together.

Infidelity: Navigating the aftermath of physical or emotional affairs.

Role Disputes: Conflict around roles and expectations within the relationship.

Addictions: Excessive/addictive behaviors that can be barriers to connection.

Sexual Dissatisfaction: Difficulties in physical intimacy or differing sexual needs.

Parenting Differences: Clashes over child-rearing philosophies or parenting roles.

Attachment Styles: Navigating closeness, autonomy, insecurity, and reassurance.

Emotional Distance: Feeling disconnected or emotionally distant from one another.

Poor Communication: Struggling to share thoughts, feelings, and needs effectively.

Conflict Resolution Problems: Inability to resolve disagreements in a healthy manner.

Family Dynamics: Issues with in-laws or blending families from previous relationships.

Financial Disputes: Conflicts over money management, spending habits, or financial goals.

Lacking Chemistry: Feeling a lack of excitement, curiosity, or interest within the relationship.

Mental Health Concerns: Navigating your, or your partner's, mental health symptoms and/or triggers.

Required

How well do you feel you and your partner manage relationship issues currently? (1-5)

Not Well at All

Very Well

Clear selection

What group times are you available to participate? *

NOTE: These are not the exact times, we just want to group people together that share the same availability.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

8AM-10AM

10AM-12PM

12PM - 2PM

2PM - 4PM

4PM - 6PM

6PM - 8PM

Would you or your partner also be interested in private couples therapy or individual therapy? *

Check any/all that apply

Private Couples Therapy

Individual Therapy for me

Individual Therapy for my partner

Not at this time

Required

How did you hear about us?

Thank you for taking the time to respond! By completing this questionnaire you will be added to our waitlist as we are putting together the next cohort of couples!

Once we review your questionnaire, we will be in contact with you about next steps.

If you have any further questions please email Allison Young, ACSW at ayoung@papercranescounseling.com

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