Christian Marriage Counseling Intake Questionnaire
Personal Information
Husband's Name
Wife's Name
Husband's Date of Birth
Wife's Date of Birth
Address
Husband's Phone
Wife's Phone
Husband's Email
Wife's Email
Children (Names & Ages)
Marriage Details
Number of years married
Previous marriages?
None
Husband
Wife
Both
Reason for seeking counseling
How would you describe your marriage currently?
Spiritual Background
Husband's Church Affiliation
Wife's Church Affiliation
Husband's Faith Journey
Wife's Faith Journey
What is your vision for your marriage?
Counseling Goals
What do you hope to accomplish through counseling?
Any specific concerns or questions for your counselor?