Couples Intake Form

 

Marriage Intensive Program - Intake Assessment

Marriage Intensive Program

Intake Assessment

Welcome!

Let's start with some basic information about you and your relationship. This helps us understand your unique situation.

Safety First

These questions help us ensure couples therapy is safe and appropriate for your situation. Please answer honestly.

Your Motivation

Understanding your readiness helps us provide the best support for your journey.

Not at all motivated Extremely motivated
Not at all motivated Extremely motivated

Faith & Values

Understanding your spiritual background helps us tailor our approach to align with your values.

Your Relationship

Tell us more about where things stand in your relationship right now.

Very dissatisfied Very satisfied

Understanding & Agreement

Please read each statement carefully and provide your initials to indicate your understanding and agreement.

I understand that the Relationship Coaches are not licensed counselors. We offer pastoral counseling and relationship and life coaching to individuals and couples. Those needing clinical work will be referred to appropriate counselors.
I understand that Dr. Smalley employs various techniques to assist both individuals and couples. People are distinct and exceptional, so the approaches used to help them must be flexible. We don't just concentrate on past problems, but instead, we teach individuals and couples relationship skills that encourage healthier, more intimate, and peaceful relationships.
I understand that all things are kept confidential except in three primary areas: 1) suicidal ideations or intent, 2) child or elderly abuse and/or neglect, and 3) homicidal ideations or intent.
I understand that Dr. Smalley reserves the right to refer any individual or couple to another counselor or licensed professional should they deem that it is in the best interest of the client(s).
We pledge to be completely honest in our discussions in order to improve our marriage and family relationships. We understand this may entail discussing difficult or embarrassing topics. We agree to address any issues in our marriage and with our spouse with respect and goodwill.
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