Today's Date: _______________
Are you interested in Premarital ____ or Married ____ coaching?
Man’s Name __________________________________________ DOB _______________
Women’s Name _______________________________________ DOB _______________
Address:______________________________________________________________________________
Contact Phone Numbers:
Home: _________________________________ His _________________________________ Hers
Cell/Other: _________________________________ His _________________________________ Hers
Is it OK to leave messages? (Circle one) yes no
Email: _________________________________ His _________________________________ Hers
Wedding Date: ____________________ Have You been married before? Him: yes no Her: yes no
Children Information: (Please list names, ages, and gender): ___________________________________
___________________________________________________________________________________
On a scale of 1 to 10, how would you rate your relationship today? Man: _________ Woman _________
What prompted you to seek coaching? _____________________________________________________
How did you find out about Marriageteam? __________________________________________________
What are your expectations or objectives from coaching? (Use back if necessary)
Are you currently engaged? (Circle one) yes no N/A
Are you currently living together? yes no
Do drugs or alcohol have any effect on your relationship? yes no
Does pornography have any effect on your relationship? yes no
Is there a history of depression or mental health issues? yes no
Does physical, emotional, or verbal abuse effect your relationship? yes no
Please explain if necessary: _____________________________________________________________
Faith: Protestant ____ Catholic ____ Jewish ____ Interfaith (two different faiths) _____ Non Believer _____
Would you like to receive our Newsletter? yes no
Emergency Contact: Name ____________________________ Phone: _________________________
Price: Married coaching $160; Premarital call for details.
Payment arrangements can be made upon request - please contact MarriageTeam for details. There is a money back guarantee; If you are not satisfied with your coaching experience, you will be given a refund if you request it in writing.
Return Couple Agreement and this Intake Form for Coaching with a check or money order to:
MarriageTeam, P.O. Box 3086, Vancouver, WA 98687-3086. If you have questions, please call (360) 450-6042 or email info@marriageteam.org
MarriageTeam is a nonprofit organization that strengthens and saves marriages to create strong families and communities. In response to community needs, MarriageTeam provides this service at approximately one-tenth of normal costs of similar services. We are, therefore, heavily dependent upon donations and are deeply appreciative to all who feel they can support our mission to improve and save marriages.
