Marriage Mentor Application

We’re so glad you are interested in marriage mentorship. Our hope is to partner you with a mentor couple who will walk alongside you in your marriage. Please take a moment to complete this brief form so we can make the best match possible for you.

Name(s)

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Husband Cell

(###)

###

####

Wife Cell

(###)

###

####

Husband Email

Wife Email

Wedding Anniversary Date

YYYY

Are you a follower of Jesus Christ?

We both are.

Husband, not wife.

Wife, not husband.

Do you attend weekend services New Life Church?

Yes (2+ times a month)

Occasionally (1 or less times a month)

No (We do not attend New Life)

Please list your top three preferences of days of the week to meet with your mentor couple.

Example: Sunday, Tuesday, Friday

Any children? Please list names, ages, and gender (if applicable).

Example: John, 14, Male

Previously married?

If yes, please provide context:

How would you rate your marriage?

1 = NOT Happy, 10 = VERY Happy

In specific terms, what are you hoping that a marriage mentor couple will help you accomplish?

Have you and your spouse talked about and agree that marriage mentoring is what you would like to do?

Comment on previous question.

Please list any area of serious conflict that would be important for us to know before assigning you to a mentor couple.

Have you received counseling/pastoral care before?

If yes, please explain circumstances.

By checking the box below, we affirm that we have read and understand New Life's Marriage Mentoring Confidentiality Statement (SEE BELOW).

I have read and agree to to the New Life Marriage Mentoring Confidentiality Statement.

Confidentiality Statement

Methods

Our Premarital Mentors will be using an inventory called SYMBIS (Save Your Marriage Before It Starts). SYMBIS increases the awareness of the strengths and growth areas of a couple, stimulates discussion of important issues, and teaches communication and conflict resolution skills. It is not intended to predict marital success and it is not to replace professional judgment.

Mentor Credentials

Premarital Mentors are godly men and women who have been married for at least five years. They are committed to God and to each other. They are not professionals in psychological counseling or psychiatric therapy and are not licensed. They have gone through SYMBIS training and receive supervision from the Marriage Pastor at New Life Church. If the mentors discover issues that they are not trained to handle, you may be referred to a professional counselor.

All communication between you and you mentors is considered confidential, except as required by law (i.e., where there is a threat of serious harm to self or others, as in the case of child abuse, suicide, or homicide). The mentors will also be receiving supervision from trained personnel.