MARRIED LIFE WITH REGGIE & LONDON PREMARITAL SURVEY
GENERAL INSTRUCTIONS

1. Please complete the couples assessment below in its entirety.

2. All counseling will be assessed a fee of $100.00 per hour.

3. Should you have any questions regarding marital counseling or the couples assessment, please email us @ royalbooking@lifelinechicago.com.

4. All information will be kept confidential.
Email address *
PRE-MARITAL SPIRITUAL GUIDANCE SURVEY
GENERAL INFORMATION
Today's Date *
MM
/
DD
/
YYYY
Your Name *
Your answer
Address *
Your answer
Home Telephone *
Your answer
Work Telephone *
Your answer
Your Age *
Your answer
Fiancé/Spouse Name *
Your answer
Are you now engaged? *
Pre-Marital Sex ? *
Are you currently living together? *
Length of Association: *
Your answer
Previous Marriage(s)? *
If yes, how long? *
Your answer
Choose One: *
Marriage ended because of (please check all that apply): *
Required
Children? *
If yes, how many? *
Your answer
Choose One *
Child(ren) from previous marriage(s)? *
Children born out of wedlock? *
Are you currently working a job receiving income? *
Monthly income? *
Your answer
Name of Employer *
Your answer
Do you have any debt? *
Do you have any savings accounts? *
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