Couples screening form

1
Your name
First Name
Last Name
2
Your date of birth
3
Partner/spouse name
First Name
Last Name
4
Your partner/spouse's date of birth
5
Relationship status
6
How long have you been in a relationship?
7
Are you in a mutually agreed upon open sexual relationship, i.e., swinging, multiple partners, etc.?
8
Are children involved?
9
Why are you seeking relationship counseling?Check all that apply.
10
Current legal status
11
Commitment to the relationship
12
Please briefly describe your relationship issue.
Huge
Large
Normal
Small
Ok
Ok
13
Email
example@example.com
14
Phone Number
Please enter a valid phone number.
15
Would you like to use your insurance benefits?We accept Blue Cross Blue Shield, Cigna/Evernorth, United, and Aetna insurances. We also accept Medicaid (LHC, Healthy Blue, and Amerihealth).
YESNO
Should be Empty: