New Client Questionnaire

September 9, 2010 by YourHealthRelationship.com Leave a Comment

In order to make the most of our time together, it is important for me to understand some basics about you, your spouse and your relationship. Please complete the form below and submit to me before your first session.

Please Note: Amy and Your Healthy Relationship understand the sensitive nature of your responses and are committed to keeping your information confidential. Please view our confidentiality policy here: CLICK HERE TO DOWNLOAD

New Client Questionnaire

Today's Date
YOUR INFORMATION:
Name*
First Last
Your Primary Email*
Birthdate*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone
Profession*
Number of Years Married to Current Spouse*
If you have Children, please enter names and ages:
If you've been married before, please list length of each marriage
SPOUSE'S INFORMATION
Spouse's Name*
First Last
Spouse's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Spouse's Birth Date*
Spouse's Profession*
If your spouse has been married before, please list length of previous marriage(s)
RELATIONSHIP INFORMATION
Have you ever sought professional counselling or relationship coaching before?*
- Yes
- No
What is your primary reason for seeking relationship coaching?*
Please describe the primary challenge in your relationship:*
Please share 3 adjectives to describe you mother and 3 adjectives to describe your father.*
Health Checklist
Please check all that apply.
Anxiety
- You
- Your Spouse
- Child/Children
Depression
- You
- Your Spouse
- Child/Children
Alcohol/Substance Abuse
- You
- Your Spouse
- Child/Children
Extreme Stress or Anger
- You
- Your Spouse
- Child/Children
Workaholic
- You
- Your Spouse
Food Addiction
- You
- Your Spouse
- Child/Children
Excessive Spending/Gambling or Money Challenges
- You
- Your Spouse
Sexual Addiction
- You
- Your Spouse
Poor Health or Health Challenges
- You
- Your Spouse
- Child/Children
Please enter the two words and then submit.

Filed Under: Client Resources

About YourHealthRelationship.com

Your Healthy Relationship is committed to helping you develop confident and self-fulfilling relationships by using new skills and healthy communication to bridge the gap to intimacy. To Schedule a 20 Minute Complimentary Consultation with Amy, CLICK HERE.

New Client Questionnaire

New Client Questionnaire

YOUR INFORMATION:

SPOUSE'S INFORMATION

RELATIONSHIP INFORMATION

Health Checklist

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