Couples information form

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 coach

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.

What do you do for a living?

How many children do you have together?

Have you ever been divorced?

Yes
No

If yes, how many times?

If divorced before, how did that end? (widowed, divorced, annulled)

How many step-children do you have (if any)?

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.

Have you or your spouse ever been diagnosed with a disorder by a psychiatrist or psychologist?

Yes
No

If yes, please explain.

Has there ever been any abuse in your relationship?

If yes, please explain

What's your strongest personality style? (The one you scored the highest in)

If you do not already know, please take the personality assessment here: http://smalley.cc/marriage-assessments/free-personality-test. Then come back and choose the correct style.

What are you goals for the intensive?

i.e. My goals are: 1.... 2.... 3.... 4....

Briefly explain why you are coming to our intensive

What would you say is the #1 problem in your relationship? Please explain your answer.

Do you ever dream of being with someone else who could make you happier?

Yes
No
I do sometimes but do not dwell on it

When your feelings get hurt or you become upset, how do you typically react?

I tend to do a lot of yelling
I just want to shut down and get away
I might lash out verbally with a hurtful statement
I imagine what my partner is feeling or thinking
I might yell but then tend to shut down or escape
All of the above

If you could undo one thing your partner has done to hurt you in the past, what would that be?

How much hope do you have that your relationship will get better?

Choose on a scale from 1 to 10 (1 being no hope at all and 10 being very hopeful).

Do you attend a church?

If yes, then which denomination?

How does your spiritual faith play a role in your relationship?

Have there been any addictions (alcohol, drugs, prescription drugs, sexual, pornography) in the past or present?

Yes - currently
Never
Yes - but it's in the past

If yes, please explain and please input recovery dates if applicable.

Are either of you currently on any preseciption medications? If yes, please explain.

What do you think your spouse would say is the main problem in the marriage?

How long have you been married?

How did you find out about the Marriage Restoration Intensive program?*

I agree to intensive terms and conditions.*

Yes
No

You can view terms and conditions at http://hope.smalley.cc/intensive-terms-and-conditions

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