Couples information form

Please fill out the following form to the best of your ability. For location and map information, please click here.

Name
FirstLast
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Email
Phone
Your date of birth*
Spouse's date of birth*
The date of your intensive (if not scheduled yet, leave blank)
Your marriage consultant
Please upload a picture of yourselves
If you have a photo, we'd love for you to upload that now so we can better recognize you when you arrive to our facility.
Please rate your marriage right now on a scale from 1 to 10*
Please check one of the following statements that best describes how you feel about the future of your relationship.*
- 5 - I want desperately for my relationship to succeed, and would go to almost any length to see that it does.
- 4 - I want very much for my relationship to succeed, and will do all that I can to see that it does.
- 3 - I want very much for my relationship to succeed, and will do my fair share to see that it does.
- 2 - It would be nice if my relationship succeeded, but I can’t do much more than I am doing now to make it succeed.
- 1 - It would be nice of it succeeded, but I refuse to do any more than I am doing now to keep the relationship going.
- 0 - My relationship can never succeed, and there is no more that I can do to keep the relationship going.
Briefly explain why you are coming to our intensive*
I agree to intensive terms and conditions.*
- Yes
- No
You can view terms and conditions at http://hope.smalley.cc/intensive-terms-and-conditions