STOP! **NOT ACCEPTING NEW CLIENTS AT THIS TIME**
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Step 2: Relationship Information
Now, let's talk about your relationship. Describe your relationship and needs.
Are you currently:
*
Is your partner in agreement that couples counseling is necessary in your relationship at this time?
*
Briefly describe your relationship (please note this is completely confidential):
*
What is the biggest challenge you face in your relationship?
*
If you are accepted as a new client, what are the three goals you desire to achieve in your relationship?
*
Why is it so important to you that your relationship is successful?
*
What do you feel will be the biggest benefit to obtaining couples therapy?
*
On a scale of 1 (lowest) to 10 (highest), how willing and able are you (and your partner) to invest the times, money, and resources into creating a healthy relationship?
*
1
2
3
4
5
6
7
8
9
10
Where would you like to be 6 months from now in your relationship?
*
Is there any additional information you would like to share with Kiaundra as she considers you and your partner for couples counseling?
*
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Step 4: Submit Answers
Please make sure to review your answers before submitting this questionnaire.
We respect your privacy.
Your information will not be disclosed or shared.
Submit
Should be Empty: