Partner 1 Name* First Last Partner 1 Date of Birth* MM slash DD slash YYYY Email* PhonePartner 2 Name* First Last Partner 2 Date of Birth* MM slash DD slash YYYY Relationship Status* Have you had previous couples therapy?* Relationship Issues* Select All Affection Agreeing on chores Closeness Common Interests Common Goals Communication Finances Friendships Guilt/Shame Having fun together Holding other back Housing Infidelity In-laws Jealousy Parenting Physical fighting Recreation Relatives Sexual Issues Showing appreciation Solving problems together Please select all that applyWhat is your biggest strength as a couple?*Has divorce/separation been considered by either party?*How long have you and your partner been together?*CommentsThis field is for validation purposes and should be left unchanged.
