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Pre-Marital Counseling In-Take Form
Please complete this form together as a couple. Your responses will help us tailor the counseling sessions to your relationship.
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Email
*
Your email
Full Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Occupation
Your answer
Church Affiliation
Your answer
Groom's Full Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Occupation
Your answer
Church Affiliation
Your answer
Address
Your answer
Bride’s Phone Number
Your answer
Groom’s Phone Number
Your answer
Bride's Email
Your answer
Groom's Email
Your answer
Wedding date (if known)
MM
/
DD
/
YYYY
Have either of you been married before?
Yes
No
Clear selection
Do you have children from previous relationships?
Yes
No
Clear selection
Why do you want premarital counseling?
Your answer
What topics would you like us to address?
Finances
Communication
Sex
In-laws
Children
Conflict
Faith
Roles in Marriage
Expectations
Counseling Sessions needed:
*
Select the package that best suits your needs.
One-time session - $80
Half Package Continued Counseling 4 Sessions - US$320
Basic Package 8 Sessions - US$640
Full Package 12 Sessions w/one-on-one (Husband to husband, Wife to wife) - $960.00
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