MARRIED LIFE WITH REGGIE & LONDON PRE-MARITAL SURVEY
GENERAL INSTRUCTIONS

1. EACH FIANCE, 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
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DD
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YYYY
Name of Person completing assessment (First/Last): *
Your answer
Address *
Your answer
Home Telephone *
Your answer
Work Telephone *
Your answer
Your Age *
Your answer
Fiancé's Name (First/Last): *
Your answer
Fiancé's Age: *
Your answer
Are you now engaged? *
Pre-Marital Sex ? *
Are you currently living under the same roof? *
Length of Association (Years/Months): *
Your answer
Children? *
If yes, how many (please specify gender)? *
Your answer
Have you been married before? *
If yes, how long (Years/Months)? *
Your answer
Choose One: *
Marriage ended because of (please check all that apply): *
Required
Children 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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