Pre-Marital Counseling Consent and Intake Form
Personal Information
Partner 1 Full Name
Partner 2 Full Name
Birthdate (Partner 1)
Birthdate (Partner 2)
Phone (Partner 1)
Phone (Partner 2)
Email (Partner 1)
Email (Partner 2)
Address
Relationship Details
Relationship Status
Engaged
Dating
Other
Wedding Date (if set)
How long have you been together?
Have either of you been married before? If yes, please specify.
Counseling Goals
Why are you seeking pre-marital counseling?
Are there particular issues or topics you wish to address?
Background Information
Have you attended counseling before (either individually or as a couple)?
Significant family, cultural, or religious considerations?
Emergency Contact
Emergency Contact Name
Relationship
Phone Number
Consent and Agreement
I/we have read and understand the information about pre-marital counseling. I/we consent to participate.
Signature Partner 1
Date
Signature Partner 2
Date