Premarital Counseling Intake Form
Personal Information
Partner 1 Full Name
Partner 2 Full Name
Partner 1 Date of Birth
Partner 2 Date of Birth
Partner 1 Contact Number
Partner 2 Contact Number
Partner 1 Email
Partner 2 Email
Address
Relationship Information
Length of Relationship (years/months)
Anticipated Wedding Date
Referred By
Have either of you been married before?
No
Partner 1
Partner 2
Both
Do you have children?
No
Yes
Describe your goals for premarital counseling
Are there any specific concerns you want to address?
Background Information
Describe any challenges in your relationship
Previous counseling experience (individual or as a couple)
Additional Information
Anything else you'd like your counselor to know?