Couples screening form

1
Your name
First Name
Last Name
2
Your date of birth
3
Partner/spouse name
First Name
Last Name
4
Your partner/spouse's date of birth
5
Relationship status
6
How long have you been in a relationship?
7
Are you in a mutually agreed upon non-monogamous (open) relationship?Ex: Swinging, sexual relationships with other people besides partner
8
Are children involved?
9
Why are you seeking relationship counseling?Check all that apply.
10
Current legal status
11
Commitment to the relationship
12
Phone Number
Please enter a valid phone number.
Should be Empty: