Couples Relationship Crisis Questionnaire Form
Please complete this Couples Relationship Crisis Questionnaire Form to help us understand your situation and support your relationship needs.
Partner 1 Full Name
*
First Name
Last Name
Partner 2 Full Name
*
First Name
Last Name
Best Contact Email
*
example@example.com
How long have you been together?
*
Please Select
Less than 1 year
1-3 years
4-7 years
8-15 years
16+ years
Briefly describe the current relationship crisis.
*
How long has this crisis been present?
*
Please Select
Less than 1 month
1-3 months
4-12 months
More than a year
What are the main topics or issues causing conflict?
*
Communication
Trust
Finances
Intimacy
Parenting
Extended family
Other
How would you describe your current communication patterns?
*
Open and honest, but often emotional
Avoidant or withdrawn
Frequent arguments or raised voices
Calm and constructive
Other
Are there any immediate safety concerns (e.g., risk of harm to self or others)?
*
No
Yes
Have you previously sought support for this crisis?
*
No
Yes, counseling or therapy
Yes, family/friends
Other
What do you hope to achieve and what is your preferred next step?
*
Submit
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