Marriage Counseling Request Form

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Marriage Counseling

Email *

First and Last name (legal name) Your name *

Your age? *

First and Last name (legal name) Your Spouse *

Your spouses age? *

Your email *

Your spouses email *

Your complete address: Street number, street, city, state and zip *

Your spouses address: Street number, street, city, state, and zip (unless you live at the same residence).

Your phone number *

Your spouses phone number? *

Why are you seeking counseling? Answers are kept confidential. Please put reasons here even if you have left a message via text, email, DM and/or FB Messenger. If you and your spouse has separate issues, prefix them as such i.e. Wife: My issues are......... Husband: My issues are....... *

What is the best time and day to set up a meeting? *

Do you agree to put in every effort to get the most out of these counseling sessions? *

Yes

Will both husband and wife attend the counselling sessions? We cannot have an effective counselling sessions if both parties are not there. We require both parties to attend all sessions. If you disagree, we cannot counsel you. *

I agree.

I disagree.

You must agree to all of the following: *

You agree that neither you nor anyone on your behalf, shall not summon Masjid al-Mu'min of Pittsburgh mediator/counselor to appear in Court.

You also agree that neither you nor anyone on your behalf shall issue any type of discovery requests to Masjid al-Mu'min or its mediators/counselors.

No recording devices of any kind are allowed except by the mediator/counselor for reference purposes. Your information is confidential and will not be used outside the counseling session.

Absolutely no yelling, shouting, or foul language will be used.

Listen attentively and be an active participant in every session.

Respect must be given at all times, even when there is a disagreement.

All counseling will be held via Zoom unless we meeting in person at Masjid al-Mu'min of Pittsburgh is practical for all parties involved.

I understand that I have to pay for each session before it is scheduled. Unless we are in the middle of a session and want extended time, I will pay for the additional time during the counselling session.

The marriage counselors/mediators have the right to decline counseling if it infringes on the rights of each spouse and the counselors/mediators that are involved.

That you may be asked personal information that is relevant to the marriage counseling session that may be uncomfortable but is necessary. All information shared is confidential and will not be used outside the counseling session.

Any and all Domestic Violence. PFA's, current police involvement and other serious civil/criminal matters must be referred to law enforcement by the couple and those involved.

Required

Today's Date *

YYYY

Send me a copy of my responses.

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