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Clinic Questionnaire
Clinic Questionnaire
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* Indicates required question
Email
*
Your email
First Name
Your answer
Last Name
Your answer
Partner Name
Your answer
Phone
Your answer
Preferred Language
English
Spanish
Clear selection
Are you married?
Yes
No
Clear selection
Do you live together?
Yes
No
Clear selection
How long have you been together?
Your answer
Do you have any kids?
Yes
No
Clear selection
If yes, how many?
If none, leave blank or enter "0"
Your answer
Why are you seeking help today?
Please select all that apply
Sex
Loneliness
Infidelity
Time apart
Irritating habits or behaviors
Unmet expectations
Friends, family, or other non-marital relationships
Household responsibilities
Children and parenting
Financial problems
Other:
How long has this been going on?
Your answer
In your own words, how is this issue affecting your relationship?
Your answer
What is your preferred outcome for your marriage?
I want to save my marriage.
I want to give up on my marriage.
I don't know what I want to do.
Clear selection
Are both partners in agreement to receive professional support?
Yes
No
Clear selection
Are you both willing and able to travel?
Yes
No
Maybe
Clear selection
Submit
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