Clinic Questionnaire
Clinic Questionnaire
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Email *
First Name
Last Name
Partner Name
Preferred Language
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Are you married?
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Do you live together?
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How long have you been together?
Do you have any kids?
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If yes, how many?
If none, leave blank or enter "0"
Why are you seeking help today?
Please select all that apply
How long has this been going on?
In your own words, how is this issue affecting your relationship?
What is your preferred outcome for your marriage?
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Are both partners in agreement to receive professional support?
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Are you both willing and able to travel?
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