SHBSF Intake Form

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SHBSF Intake Form

Please answer all questions if possible. Some questions are required to ensure we are able to provide the services you need and some questions are optional but will allow us to prepare for our consultation call with better insight. We are excited to work with you!

Email *

First and Last Name *

Occupation

Are you married? *

If so, how many years?

Are you currently living together?

Yes

Clear selection

Do you have children? If so how many and are they living at home?

Please describe how we at Safe Haven can partner with you. *

Please list your top three issues (communication, intimacy, trust, finances, priorities, etc.)

How does God/faith play a role in your marriage?

Are you personally struggling with grief, deep emotional pain, unresolved resentment, and/or unforgiveness? If so, please elaborate.

Are you currently taking any medications?

Yes

Clear selection

Are you dealing with Abuse in your marriage, including but not limited to physical or emotional abuse? *

Yes

If yes, please elaborate:

Are you currently dealing with any addictions? (sexual, drug, alcohol, etc.) *

Yes

If so, please elaborate:

Are you engaged in any active affairs? *

Yes, My spouse is aware

Yes, My spouse is not aware

How did you hear about Safe Haven Building Strong Foundations? *

Please acknowledge that you have read and agree with the Safe Haven Building Strong Foundations, LLC. Ministerial Marriage Coaching Acknowledgement, Authorization and Consent Agreement. https://docs.google.com/document/d/1Z8USf42wsrfdnhaUQmQwSaVBXo3B0CfK7fJpnZVtMAw/edit?usp=sharing *

I have read and acknowledge the agreement

I have not read or I do not acknowledge the agreement

Thank you for completing! We will be in touch with you soon!

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