Couples Questionnaire

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HOLISTIC CHRISTIAN THERAPIES

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Couples Counseling

Questionnaire

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Spouse's/partner's name *

Have you had couples counseling before? *

Yes No

MEN: Do you feel respected by your spouse/partner? If not, what makes you feel disrespected? *

For men to complete; women skip this question

WOMEN: Do you feel loved by your spouse/partner? If not, what makes you feel unloved? *

For women to complete; men skip this question.

What is your biggest complaint about your spouse/partner? *

Are you holding any unforgiveness in your heart toward your spouse/partner? If so, what are you having a hard time forgiving? *

What do you need from your spouse/partner that would improve your relationship? *

What could your spouse/partner do when communicating with you that would improve communication for you? *

How can you improve your communication with your spouse/partner? *

What is your spouse's/partner's biggest complaint about you? *

What are you hoping to resolve as a result of couples counseling? *

I am willing to (check all that apply): *

Forgive my spouse/partner for past hurts Take responsibility for my part Practice new communication habits Ask for what I need from my spouse/partner Work toward win/win solutions with my spouse/partner Be mindful of how I speak Not verbally attack my spouse/partner Walk in obedience to the Lord with regards to my God-given role as a husband/wife Complete any homework assignment provided by my counselor

Submit

Contact Information
Stephanie Stanton, H.H.C.
Cell/Text: 201-892-3959
Email: stephmastro@gmail.com

Remote sessions available via Zoom or phone

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