Which of the following best describes what you would like help with?

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Which type of counselor do you think fits you best right now?

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How would you describe where you are right now?

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How supported do you feel right now in your daily life?

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How, if at all, does faith or spirituality relate to what you are going through?

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What would progress look like in daily life?

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Is there anything else you'd like your counselor to know before your first session? (optional)

2-3 sentences is plenty

Partner 1 — Age range

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Partner 1 — Gender

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Partner 2 — Age range

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Partner 2 — Gender

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How long have you been together?

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Preferred language for counseling sessions

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Which denomination best describes your household?

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Have you ever been in couples counseling before?

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Are both partners willing to attend sessions together?

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Would you prefer a counselor who shares your cultural or ethnic background?

Any specific preferences for your counselor?

Gender, counseling style, spiritual background, etc.

Which days are you typically available?

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What times work best?

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Partner 1 Contact

Partner 2 Contact

Home Address

Emergency Contact

Provide a trusted person we may contact if there is an urgent safety concern.

Almost Done

Safety Screening