Pre-Session Questionnaire

Pre-session Questionnaire

* Indicates required field

Name *

First

Last

What religion, if any, do you affiliate with? Please type your answer below. If no religious affiliation, type "None." *

Do you attend a local church? If so, which one? *

Previous marriages? If yes, how many? *

Have you considered or mentioned separating or divorce as a result of the current marital/relationship breakdowns? *

Yes No

Are you currently or have you recently struggled with physical or emotional infidelity (an affair)? *

Please Describe the current need for coaching from your perspective. *

What do you hope to accomplish with coaching (your goals)? *

Please describe other stressors, whether in the relationship or personal, you would like to include: *

Please rate the following on a scale of 1 (being very low) to 5.

DISCLOSURES

Coaching sessions are 90 minutes long & your payment of $85 is due at least 72 hours prior to your appointment. Balances need to be paid in full before we can confirm an appointment. If for any reason you need to reschedule an appointment, please contact our office or your coaching couple directly. There is a $50 cancellation/no show fee for sessions not cancelled within 72 hours of the appointment time. After your initial visit, should you voluntarily choose to enter into an ongoing, coaching relationship with one of our coaching couples, we recommend that you schedule a series of at least 3-5 appointments to accomplish the goals that you & your partner established with your coaches. We also ask that you complete all homework assignments in their entirety & on time. These assignments are designed to create a way for you & your partner to immediately begin implementing the tools & skills you learn in your coaching session.

Please initial to indicate that you have read, understand & agree with the above statement *

The job of your coaches is to ask you & your spouse/partner what kind of marriage/relationship you want - what you want it to look like. They will then assist you in setting the goals & determining the action steps needed to get you there. You will each be responsible for your part in achieving the marriage/relationship you've always dreamed of. Your coaches will "coach" you to use the tools you learn in your sessions through the real life issues you are facing as you are empowered & equipped as a couple.

Please initial to indicate that you have read, understand & agree with the above statement *

I UNDERSTAND THAT COACHES WITH MARRIAGE & FAMILY WORKS ARE NOT LICENSED THERAPISTS, COUNSELORS, PSYCHOLOGISTS, PSYCHIATRISTS OR MEDICAL DOCTORS. WE DO NOT CLAIM TO BE THERAPISTS, OFFER THERAPY OR GUARANTEE MARITAL RECONCILIATION. The services provided by Marriage & Family Works are not a substitute for counseling, therapy, psychiatric care or medication.
The biggest difference is the formal education and degrees that a therapist or counselor has as a basis to help people. All of our coaches have been trained in many relationship education programs and have their own personal experiences to share from. Since all of our coaches are volunteers, they are servants to those struggling. Coaching involves listening for the issues and offering wisdom and skills. Our coaches are trained to share hope with those in need.

I understand that any information shared during my coaching sessions will remain confidential between myself, my partner & our coaches. The coaches may at times share appropriate information with the Marriage Coach Supervisor if deemed necessary. Information may be released, in accordance with state or federal law only when:
1) I provide Marriage & Family Works with a signed, written release of information indicating informed consent to such release;
2) I express serious intent to harm myself or someone else;
3) There is evidence or reasonable suspicion of abuse against a minor child, elderly person or dependent adult;
4) A subpoena or other court order is received directing the disclosure of information.
If I have any questions or concerns regarding this policy, I agree to contact Marriage & Family Works staff at the earliest possible time. I understand that at any time I can terminate my relationship with Marriage & Family Works or request a new coaching couple if I am unhappy or dissatisfied with my coaches.

Please initial to indicate that you have read, understand & agree with the above statement *

I consent to being contacted by Marriage & Family Works by phone, text, and/or email regarding future appointments & events *

Yes No

Please initial to indicate that you have read, understand & agree with the above statement *

Please digitally sign below to indicate that you have read, understand & agree with all of the information within the disclosures section. Your typed name in this box constitutes a digital signature *

Date *

Demographic Information
This information is requested as a way to internally track our organization's impact within the community. Because our organization is a not for profit, this information also assists us with funding to continue our mission.
We respect your privacy & all information gathered is stored anonymously. We will never use personally identifiable information, such as names or dates of birth, when analyzing our data.
We would love for you to answer all of the demographic questions; however, you may choose to answer one, none or some.

What is your gender? *

Male Female Prefer not to say

What is your age range? *

What race best describes you? *

Are you of Hispanic, Latino or Spanish Descent? *

Yes No Prefer not to say

What is Your Occupation? *

Pre-session QUESTIONNAIRE

Pre-session Questionnaire

DISCLOSURES