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Email *
Name *
Address
City, State, Zip
Phone Number *
Email *
Day Phone
Evening Phone
Occupation - Employer - Company Name
Birthday
MM
/
DD
/
YYYY
Contact in Case of Emergency:
Spouse - Partner Name
Children's Names - Ages
What or who motivated you to meet with me? *
What is your relationship/marriage status? *
If the relationship/marriage is ending, are you the initiator or is the other person the initiator? *
Duration of relationship/marriage? Is this your first, second, or more relationship/marriage?
Are you still together or have you separated?  If separated how long? *
What other people or resources have you met with or explored relative to your situation? *
What are the 3 biggest concerns and most important outcomes that you want to have? *
What do you see as a next step for you, both short term and long term? *
Are you in fear of your safety or for the safety and well-being of others in your household? *
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