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Let's Talk Counsel – LTC
letstalkcounsel@gmail.com
(774)-303-2216
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Home
About
Services
LTC Application
LTC Marriage Counseling
Feedback
Blog
Contact
Book Appointment
LTC Marriage Counseling Form
1. Personal Information
Full Name
*
Date of Birth
*
Age
*
Gender
*
Female
Male
Non-binary
Other
Prefer not to say
Phone Number
*
May we leave you a voicemail?
*
Yes
No
Email Address
*
Street Address
*
City
*
Occupation
Employment Status
Employed
Self-employed
Unemployed
Student
Retired
Other
Prefer not to say
Emergency Contact Name and Number
*
2. Relationship History
Partner's Full Name
*
Relationship Status
*
Dating
Engaged
Married
Separated
Divorced
Total Time Together (years/months)
*
Years Married (if applicable)
Do you currently live together?
*
Yes
No
Have you ever previously separated?
*
Yes
No
If yes, how many times and for how long?
Have you had any previous marriages?
*
Yes
No
If yes, how many?
Please briefly list how/when they ended.
Do you have children?
*
Yes
No
Please list their names, ages, and whether they are from this or a previous relationship.
3. Counseling Goals & Current Concerns
Why are you seeking marriage counseling at this time?
*
Treatment Objectives (Check all that apply)
*
Improve communication
Better conflict resolution
Rebuild trust / Address infidelity
Increase emotional intimacy
Increase sexual intimacy
Navigating parenting differences
Financial disagreements
Deciding whether to stay together
On a scale of 1–10, how committed are you to preserving this relationship? (1 = Not at all, 10 = Fully)
*
1
2
3
4
5
6
7
8
9
10
4. Relationship Health & Safety Indicators
Has either you or your partner consulted a divorce lawyer?
*
Me
Partner
Both
No
Do you perceive that either of you has withdrawn from the relationship?
*
Me
Partner
Both
No
Has there ever been physical violence, threats, or restraint in this relationship?
*
Yes
No
If yes, please describe (only share what you feel safe sharing).
5. Emotional & Physical Well-being
Rate your current personal stress level
*
Low
Moderate
High
Rate your relationship stress level
*
Low
Moderate
High
Are you currently experiencing any of the following? (Check all that apply)
Anxiety / Panic
Depression / Sadness
Substance abuse / Addiction issues
Severe sleep disturbances
Are you currently seeing an individual therapist or psychiatrist?
*
Yes
No
Are you currently taking any prescription medications?
*
Yes
No
Please list any current prescription medications:
6. Patient Consent Form for Christian Counseling
Full Name
*
Address
*
DOB
*
Email
*
Phone/Cell
*
Parent/Guardian/Self (select what applies)
*
Parent
Guardian
Self
Signature
*
Date
*
Submit Intake Form
