Interfaith Relationship Counseling Intake
Contact Information
Name (Partner 1)
Name (Partner 2)
Email (Partner 1)
Email (Partner 2)
Phone Number (Partner 1)
Phone Number (Partner 2)
Relationship Details
Length of Relationship
Relationship Status
Dating
Engaged
Married
Other
Do you have children together? If yes, please specify ages
Religious & Cultural Backgrounds
Partner 1 - Faith/Tradition
Partner 2 - Faith/Tradition
Partner 1 - Cultural Background
Partner 2 - Cultural Background
Counseling Goals & Concerns
What are your main goals in seeking counseling?
What interfaith or intercultural challenges are you experiencing?
Have you attended counseling together before? If yes, please describe