Pre-Screening Form | Intimacy Counseling

What is bringing you to consider a marital intensive at this time?

Are both of you willing and available to participate fully in both days?

Yes, both of us are fully committed

We're interested but need to confirm schedules

One of us is more uncertain — we want to learn more first

Is there any current concern about safety in the relationship — including physical conflict, threats, or fear of a partner's reaction?

No, we feel safe

There has been conflict but no physical safety concern

I am not comfortable answering with my partner present

Yes, there is a safety concern I would like to discuss privately

Is either of you currently managing a significant mental health concern — such as active depression, a recent crisis, or a condition currently requiring psychiatric support?

No, we're both stable

One of us is managing something, well-controlled

Yes, there's an active concern I'd like to discuss

Partner A: What would it mean to each of you personally — not just for the relationship — if things were different after these two days?

Partner B: What would it mean to each of you personally — not just for the relationship — if things were different after these two days?

By submitting this form, you confirm that both partners are aware it is being submitted. This form does not establish a clinical relationship. We will follow up within 2 business days

(No need to type anything here)

Thank you for your interest. Before we schedule a consultation call, please complete this brief form together. Both partners should be present and aware that this form is being submitted.