Couples Counselling Referral Form Marriage/Couples Counselling Referral Form Your Name* First Last Your Partners Name* First Last Contact Email* Contact Phone*How long have you been together?*Do you have children?*YesNoHas one or both of you talked about separating or divorce?*YesNoHave one or both of you been charged with assault?*YesNoDo 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?*YesNoIs one of you a step parent?*YesNoAre 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?* Share this:TweetWhatsAppMoreShare on TumblrEmailTelegramLike this:Like Loading...
