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 Ministry Intake Form

Personal Information

Name(Required)
MM slash DD slash YYYY

Relationship Status

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

Marriage Mentoring Goals

Not concerning at allSlightly concerningModerately concerningVery concerningExtremely concerning
Extremely unhappyVery unhappyNeutralVery happyExtremely happy
Extremely unsatisfiedVery unsatisfiedNeutralVery satisfiedExtremely satisfied

Top Concerns

Please list your top three concerns about your relationship.