Couples Questionnaire
Please fill out the following questions to help us understand your relationship better.
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Partner's Full Name
*
First Name
Last Name
Partner's Email Address
*
example@example.com
Date of Meeting or Session
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How long have you been together?
*
Less than 6 months
6 months to 1 year
1 to 3 years
3 to 5 years
More than 5 years
Relationship Status
*
Please Select
Dating
Engaged
Married
In a civil partnership
Complicated
Other
What are your main goals for this session?
On a scale of 1 to 10, how satisfied are you with your relationship?
*
Lowest (1)
1
2
3
4
5
6
7
8
9
Highest (10)
10
1 is Lowest (1), 10 is Highest (10)
Do you have any concerns you'd like to discuss?
Communication issues
Trust issues
Financial concerns
Intimacy problems
Other
Submit
Should be Empty: