Name: Crystal Arber Individual Youth and Family Counselling
Address: East 13th, North Vancouver, BC, V7L 2P2

Your Name*
First Last
Your Partners Name*
First Last
Contact Email*
Contact Phone*
How long have you been together?*
Do you have children?*
Has one or both of you talked about separating or divorce?*
- Yes
- No
Have one or both of you been charged with assault?*
- Yes
- No
Do either of you suffer from substance or alcohol dependency?*
Have either of you been diagnosed with a mental health disorder such as depression, psychosis or bipolar?*
Are you both in a polyamorous relationship?*
Is your family blended?*
- Yes
- No
Is one of you a step parent?*
- Yes
- No
Are you reaching out for help as a result of an affair?*
Do one or both of you suffer from addiction or addictive behaviours in the relationship?*
Do one or both of you suffer from a traumatic childhood, or come from a home where one parent was substance dependent?*
Has your partner been diagnosed with ADD or ADHD?*