Premarital Intake Form "*" indicates required fields Step 1 of 3 33% InstagramThis field is for validation purposes and should be left unchanged.We invite you to take a few moments to complete our intake form. It typically takes around 20 minutes to finish. You can save your progress at any time and return to complete it later. Both individuals in a couple should complete their own intake form. If you have any questions, please don’t hesitate to call us at (360) 450-6042 — we’re happy to help!Contact InfoName* First Last Phone*Sex* Male Female Birth date MM slash DD slash YYYY Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your email* Enter Email Confirm Email Your partner/spouse's name* First Last Your partner/spouse's email* Enter Email Confirm Email Relationship DetailsCurrent situation: Check all that apply* Married Separated Engaged Cohabitating Dating Wedding date MM slash DD slash YYYY Future wedding date MM slash DD slash YYYY Previously married?* Yes No Number of previous marriagesFamily DetailsDo you have children? Yes No List children's ages and gendersBelief SystemTo help our coaches guide meaningful discussions, we ask couples to complete a relationship inventory provided by Prepare/Enrich. The inventory is customized to reflect your religious background. Please choose the option that best matches your experience. Religious Background* Catholic Protestant/Evangelical Interfaith Jewish Orthodox No religion Other Name of congregation or place of worship (if applicable):Promo Code (Optional): MotivationWhat prompted you to seek coaching at this time?*What are the primary concerns/issues in your relationship?* At MarriageTeam, we know every couple faces challenges — some obvious, others beneath the surface. Marriage coaching is designed to empower you to take charge of your relationship, better understand each other’s needs, and build a shared vision for the future — not to assign blame or decide who’s ‘right’ or ‘wrong.’ Our role is to walk alongside you as you grow, heal, and strengthen your marriage. In the next section, you’ll find questions about sensitive areas dealing with trust, past hurts, and current struggles. Your honest responses help us determine if coaching is the best resource for your situation. Everything you share is confidential and treated with care. Please respond openly. Questions? We’re here for you at (360) 450-6042. Drugs & AlcoholHave drugs or alcohol had any impact on your current relationship?* Yes No Which spouse is struggling with drugs or alcohol?Please explain the situation:Is this an ongoing problem? Yes No Do you believe the person could stop taking drugs or alcohol on their own? Yes No Has help been sought in the past? Yes No What was the outcome?Pornography & Sexual AddictionHas pornography or sexual addiction had any impact on your current relationship?* Yes No Please explain the situation:Is this an ongoing problem? Yes No Do you believe the person could stop this behavior on their own? Yes No Has help been sought in the past? Yes No What was the outcome?Emotional AbuseHas emotional abuse had any impact on your current relationship?*(Here's what emotional abuse might look like: relationships involving imbalance of power and control; consistent lack of mutuality; lack of freedom to speak up, have own opinions, disagree or make own choices; consistent indifference to partner's needs, feelings, desires and thoughts; blame-shifting, minimizing and lack of responsibility for wrongs committed; an attitude of entitlement; causing fear by intimidation, threatening harm to self, partner, family or friends; destruction of property; or forcing isolation from family or friends.) Yes No Please describe the abusive behavior:Has there been any police or judicial involvement regarding this issue? Yes No Please explain:Has help been sought in the past? Yes No What was the outcome?Mental HealthHave either of you been diagnosed with any mental health issues?* Yes No Please indicate name, mental health issues, formal diagnosis, and prescribed medications.Has treatment (if any) been effective?Have you or your partner suffered from or been diagnosed with depression?* Yes No Please indicate which spouse and whether the depression is being treated with medication and/or counseling.Has treatment (if any) been effective?Extramarital AffairsHas there been an affair in the past, or do you suspect one?* None Suspect an affair Past affair - emotional Past affair - physical An ongoing affair A history of affairs Please explain: Relationship Ratings & Coaching PreferencesHow would you rate your relationship? 1 (the worst) through 10 (the best)* 1 2 3 4 5 6 7 8 9 10 Coaching tends to be most effective for couples who are committed to making changes and moving forward in their relationship by addressing the challenges that may be holding them back. On a scale of 1 to 10, how would you rate your readiness to make positive changes in your relationship?* 1 2 3 4 5 6 7 8 9 10 Do you have any additional concerns about coaching?Coaching sessions typically last about two hours and are scheduled during evenings or weekends. Please share your availability so we can coordinate a suitable time.Coach couple we would like to request (Optional):How did you hear about us?* Online Facebook YouTube Friend/Family Church/Pastor Employer Other Please specify:*MarriageTeam Privacy Policy/Terms & Conditions* I agree to the Privacy Policy/Terms & Conditions.Privacy Policy and Terms & ConditionsMarriage Coaching Agreement*1. MarriageTeam coaches are trained in the coaching skills of listening, asking questions, sharing their life experiences, and most importantly, helping you resolve the issues you are facing. They want to help you be successful in your marriage. While coach couples are not lawyers, licensed counselors, therapists, or psychologists and do not provide marriage or family therapy or legal advice, they can facilitate significant improvements in many relationships. 2. Coaches will guide you through skill-building exercises, but the results of these exercises depend on your commitment to learning and applying the skills. 3. MarriageTeam asks that you commit to completing the full coaching curriculum. If you have specific concerns, bring them to MarriageTeam’s attention. 4. Although many couples report improved relationships as a result of coaching, there are no guarantees about the success of the coaching process in your unique situation. Change and growth are hard work and are accomplished best when you work together as a team. 5. Conversations with your coach couple will be held in confidence with three possible exceptions: 1) possible referral to MarriageTeam for guidance or direction or 2) reporting suspected abuse of children, the elderly or mentally ill or 3) if you were referred by a pastor, responding to your pastor’s request for general status information. 6. There are no special legally recognized “client privileges.” Coach couples could be subject to subpoena by a court and required to testify. 7. MarriageTeam has a money back guarantee. If you truly believe you did not “get your money’s worth” from your coaching experience, submit it in writing for a refund less the cost of the inventory and materials. 8. MarriageTeam is a nondenominational, faith based social agency that provides services for the purpose of demonstrating Christ’s love and moving couples toward a biblically based marriage. 9. We have read this agreement and understand that our coaches are not counselors, therapists, psychologists or lawyers, and do not provide marriage or family therapy, counseling, or legal advice. We understand that we are responsible for all decisions that we make and all subsequent actions we take. 10. As voluntary participants, we hereby release MarriageTeam, its officers, employees, and agents from liability for any and all civil or criminal claims, actions, obligations, costs, losses, or demands of any kind arising out of participation in this program or actions that we take during or after the coaching process. 11. We understand others are financially supporting our coaching through voluntary giving and that we will be given a similar opportunity at the conclusion of coaching. If you have questions, please give us a call at 360-450-6042. I understand and accept the MarriageTeam Coaching Agreement.Name* First Last Δ
