Name: Partner 1 *

First Name

Last Name

Name: Partner 2 *

First Name

Last Name

Best Contact Number

(###)

###

####

Preferred Start Date

MM

DD

YYYY

What challenges are you currently seeing in your relationship?

Communication

Emotional Intimacy

Sexual Intimacy

Trust

Inequality of Effort

Lack of Shared Interest & Goals

Differing Lifestyles

Financial Challenges

Parenting Misalignment

Unhealthy Disagreement/Fighting

Considering Separation or Divorce

Premarital Health/Evaluation

Infidelity

Other