PreEngaged Intake
This form is used for both pre-engagement and premarital clients. Please take the time to fill this out *completely*. It will take some time to fill this out well, so please allocate the appropriate time to fill it out. The more effort you put into doing this work, the better we can serve you.
General Information
First and Last Name: *
Your answer
E-mail Address: *
Your answer
Mailing Address: *
e.g., Street, City, State, and Zip Code
Your answer
Phone Number: *
xxx-xxx-xxxx
Your answer
Gender *
Date of Birth: *
mm/dd/yyyy
Your answer
In which time zone are you located? *
Demographic and Church Information
Name of Home Church: *
If not included in the name, include denomination -- If none, type "none."
Your answer
Church Location: *
e.g., City and State -- If none, type "none."
Your answer
Are you a member there?
Ethnicity: *
Marital Status: *
Options: Never Married, Divorced (if so, how many times?), Separated (if so, for how long?), or Widowed (if so, when?)
Your answer
Children:
List child's name, sex, and age for each child you have, if any.
Your answer
Highest Level of Education: *
Your answer
Occupation / Job Title and Company: *
Your answer
Current Employment: *
How satisfied are you with your job? *
Your answer
Approximate Current Household Income:
Health / Counseling / Legal Information
1. Are you presently under the care of any medical doctor / practitioner?
If yes, for what condition(s)?
Your answer
2. Are you currently taking any prescription or non-prescription medications?
If yes, please indicate type(s) and dosage(s).
Your answer
3. Are you currently receiving or have you in the last 3 years received counseling, individual or marital therapy, or been under the care of any mental health provider or addiction recovery provider?
If yes, for what issue(s)?
Your answer
4. Have you ever been a victim of sexual abuse?
5. Did either of your primary caregivers (e.g., parents) ever divorce?
6. Are you currently involved in, or anticipate being involved in, any litigation or legal action?
If yes, please explain.
Your answer
Goals of Counseling
Which of the following statements best describes your relationship? *
Goal 1: *
Please list the first goal you want to accomplish during pre-engagement/premarital counseling.
Your answer
Goal 2:
Please list the second goal you want to accomplish during pre-engagement/premarital counseling.
Your answer
Goal 3:
Please list the third goal you want to accomplish during pre-engagement/premarital counseling.
Your answer
Topics of Discussion
Topic 1: *
Please list the first topic you want to make sure to discuss during pre-engagement counseling.
Your answer
Topic 2:
Please list the second topic you want to make sure to discuss during pre-engagement counseling.
Your answer
Topic 3:
Please list the third topic you want to make sure to discuss during pre-engagement counseling.
Your answer
Background
Spiritual Background *
Discuss your spiritual background, current spiritual practices, and importance you place on spiritual matters. (500-2000 words)
Your answer
Family Background *
What is important for us to know about your family (current and history)? (500-2000 words)
Your answer
Closing Questions
1. What are the first and last names of the person with whom you want to do pre-engagement/premarital counseling? *
Your answer
2a. Have you discussed potential plans to wed in the future with your current boyfriend/girlfriend? *
2b. If "Yes" to 2a, have you discussed about when the wedding would take place?
2c. If "Yes" to 2b or already engaged, about when would/will the wedding take place?
Your answer
3. Have you shared, or do you plan to share, the information in this intake with your boyfriend/girlfriend or fiancé/fiancée?
4. How, or from whom, did you hear about us? *
If we know them, we like to bless the people who sent you - so please let us know! (If not personally referred, but one of the testimonials of our services inspired you to contact us, please type "Testimonial from " and list that person's name!) Thanks!
Your answer
5. Are there any questions you have for us or about us that you would like us to answer?
Your answer
6. Have you read, understood and agreed to the Agreement for PreEngaged’s Coaching Services? *
Required
Thank you for taking the time to completely fill out this intake!
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