Elisabeth Klein's Marriage Assessment  
The fact that you are here tells me something about you: you are brave. Truly.

Your first step in making any change in your life is to honestly assess your reality, even if it's painful to do so.

Answer the questions quickly and honestly. Don't overthink your answers, this will result in better accuracy.  

The information you provide on this form will help me understand where you are in your current situation and your overall well-being, and will be a great starting point if we decide to work together.  

Please note that your answers are 100% confidential.

 I'll be in touch shortly, to discuss how I can help you.

-Elisabeth
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Hello!
Full Name *
Best email to reach you? *
How long have you been married? *
Do you have children and/or stepchildren? If yes, how old are they? Do they live with you all the time or part-time? *
Are you currently living together or apart? *
Has your husband been unfaithful to you? *
Have you ever been unfaithful to your husband? *
Has your husband ever left you? *
Have you ever left your husband? *
Has your husband ever hit you? *
Has your husband ever hit your children (more than a spanking) *
Are you worried about your safety or the safety of your children? *
Does your husband have an addiction to alcohol or drugs? *
Does your husband have any other kinds of addictions? *
Do you have any addictions? *
Does your husband view pornography? *
Does your husband swear at you or call you names? *
Do you swear at your husband or call him names? *
Does your husband lie to you? *
Does your husband hide things from you? *
Does your husband control the money? *
Does your husband threaten you - to harm you, leave you, harm your children, to commit suicide, or harm himself? *
Does your husband damage property in his anger? *
Does your husband give you the silent treatment in his anger? *
Does your husband control who you see and what you do? *
Has your husband told you that you cannot get counseling or talk to a friend or a pastor about your marriage? *
Does your husband humiliate you in public? *
Does your husband criticize your appearance, parenting skills, housekeeping skills, intelligence, etc? *
Does your husband demand  or force sex or make you perform sex acts that you aren't comfortable doing? *
Does your husband withhold physical affection or sex? *
Does your husband use Scripture to try to control you? *
Does your husband make all or most of the decisions? *
Does your husband stalk or spy on you (follow you, read your emails, read your texts)? *
Does your husband deny you or your children basic rights like food, sleep, a warm home, etc.? *
How do your children feel about your husband?
Are you currently in (check all that apply)
They say life is a numbers game... so what are your numbers?
Please answer the next few questions based on a scale of 1 being the worst you've ever felt and 10 being amazing.
How are you feeling emotionally now? *
worst I've ever felt
amazing
How are you feeling physically right now? *
worst I've ever felt
amazing
How are you doing spiritually right now? *
worst I've ever felt
amazing
Are you open to coaching? *
If you are open to coaching, which of the following would you prefer? (you can choose more than one) *
Required
In the next six months, what is your plan/hope?
Clear selection
Is there anything else you would like to tell me? Do you have other concerns or questions?
Submit
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