Marriage Mentoring Intake Form

Thank you for your interest in marriage mentoring. The form below should be filled out privately by each spouse. Your responses to these questions will be shared with our marriage mentoring team.

Marriage Connect Intake Form

Personal Information

Name(Required)

First Last

Phone(Required)

Email(Required)

Age(Required)

Gender(Required)

Ethnicity(Required)

Anniversary(Required)

Spouse's Name(Required)

Relationship Status

What is your relationship status and living arrangement?(Required)

Married, separated, or divorced. Living together, separate beds, or separate homes.

How long were you engaged?(Required)

How long did you date before engagement?(Required)

Marriage Mentoring Goals

What is your primary reason for coming to marriage mentoring?(Required)

How serious is this issue?(Required)

What do you hope to accomplish through mentoring?(Required)

Have you received or sought professional counseling? Why or why not? What was the outcome?(Required)

What are your biggest strengths as a couple, together?(Required)

How happy are you in your relationship?(Required)

What is one thing you could do to improve your relationship?(Required)

What is one thing your partner could do to improve your relationship?(Required)

Have either of you made threats against the other person? How often and what happened?(Required)

Have either of you considered leaving the other person? Have you consulted with a lawyer regarding divorce?(Required)

How satisfied are you with your current sexual relationship?(Required)

Why? Explain your previous answer about sexual satisfaction.(Required)

Top Concerns

Please list your top three concerns about your relationship.

Concern #1(Required)

Concern #2(Required)

Concern #3(Required)

Marriage Mentoring Intake Form

Marriage Connect Intake Form

Personal Information

Relationship Status

Marriage Mentoring Goals

Top Concerns

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