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Marriage Coaching Form
Marriage Coaching Form
Noor Atisha
2021-05-21T12:50:28-04:00
1
2
3
Husband Name
First
Last
Age
Religious Preference/Identified Parish
Email
Cell Phone
Home Phone
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Wife Name
First
Last
Age
Cell Phone
Home Phone
Address (If Different Than Above)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Have you or your spouse ever been Hospitalized for a Mental Illness, Personality Disorder, Anxiety Disorder, etc.?
Yes
No
If Yes, Please Describe Below
Any previous therapy or counseling?
Yes
No
If yes please provide date(s) and number of sessions
Type of therapy
Any previous sessions with a Priest?
Yes
No
Please check all that apply to the husband:
Alcoholism
Shy With People
Suicidal thoughts
Drug Use
Eating Struggles
Obsessions
Sexual Issues
Infidelity Issues
Pornography Issues
Family Planning Issues
Sleeping Problems
Inferiority Feelings
Gambling Problems
Fears or Phobias
Depressed
Job Problems
Over Worried
Anger Issues
Financial Problems
In-Law Problems
Comparison Problems
Communication Problems
Forgiveness Problems
Transparency Problems
Boundaries Problems
Other
None
If other was chosen please explain below
Please check all that apply to the wife:
Alcoholism
Shy With People
Suicidal thoughts
Drug Use
Eating Struggles
Obsessions
Sexual Issues
Infidelity Issues
Pornography Issues
Family Planning Issues
Sleeping Problems
Inferiority Feelings
Gambling Problems
Fears or Phobias
Depressed
Job Problems
Over Worried
Anger Issues
Financial Problems
In-Law Problems
Comparison Problems
Communication Problems
Forgiveness Problems
Transparency Problems
Boundaries Problems
Other
None
If other was chosen please explain below
Please check all that apply for the Husband's Faith Life
Attend Mass Regularly
Sacrament of Confession Regularly
Pray Individually
Pray Together
None Of The Above
Please check all that apply for the Wife's Faith Life
Attend Mass Regularly
Sacrament of Confession Regularly
Pray Individually
Pray Together
None Of The Above
Has there ever been mental or physical abuse in your relationship? If yes, explain
Have there ever been any threats of violence in your relationship? If yes, explain
Questions for
HIM
to answer:
Rate Your Marriage At This Time (Husband)
On Life Support
Lousy
Could Be Better
Surviving
Good
Could Be Better
Thriving
What are you expecting from us? (Husband)
Questions for
HER
to answer:
Rate Your Marriage At This Time (Wife)
On Life Support
Lousy
Could Be Better
Surviving
Good
Could Be Better
Thriving
What are you expecting from us? (Wife)
How were you referred to the Marriage Coaching Ministry?
Privacy Statement
All personal information collected by ECRC Marriage Coaching Ministry will be held in the strictest of confidence. Contact and personal information will only be used to assist with the Marriage Coaching process and send information to you.
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