Marriage Coaching Form Marriage Questionnaire 123 Husband Name First Last AgeReligious Preference/Identified ParishEmail Cell PhoneHome PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Wife Name First Last AgeCell PhoneHome PhoneAddress (If Different Than Above) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Have you or your spouse ever been Hospitalized for a Mental Illness, Personality Disorder, Anxiety Disorder, etc.? Yes No If Yes, Please Describe BelowAny previous therapy or counseling? Yes No If yes please provide date(s) and number of sessionsType of therapyAny previous sessions with a Priest? Yes No Please check all that apply to the husband: Alcoholism Shy With People Suicidal thoughts Drug Use Eating Struggles Obsessions Sexual Issues Infidelity Issues Pornography Issues Family Planning Issues Sleeping Problems Inferiority Feelings Gambling Problems Fears or Phobias Depressed Job Problems Over Worried Anger Issues Financial Problems In-Law Problems Comparison Problems Communication Problems Forgiveness Problems Transparency Problems Boundaries Problems Other None If other was chosen please explain belowPlease check all that apply to the wife: Alcoholism Shy With People Suicidal thoughts Drug Use Eating Struggles Obsessions Sexual Issues Infidelity Issues Pornography Issues Family Planning Issues Sleeping Problems Inferiority Feelings Gambling Problems Fears or Phobias Depressed Job Problems Over Worried Anger Issues Financial Problems In-Law Problems Comparison Problems Communication Problems Forgiveness Problems Transparency Problems Boundaries Problems Other None If other was chosen please explain below Please check all that apply for the Husband's Faith Life Attend Mass Regularly Sacrament of Confession Regularly Pray Individually Pray Together None Of The Above Please check all that apply for the Wife's Faith Life Attend Mass Regularly Sacrament of Confession Regularly Pray Individually Pray Together None Of The Above Has there ever been mental or physical abuse in your relationship? If yes, explainHave there ever been any threats of violence in your relationship? If yes, explainQuestions for HIM to answer:Rate Your Marriage At This Time (Husband) On Life Support Lousy Could Be Better Surviving Good Could Be Better Thriving What are you expecting from us? (Husband) Questions for HER to answer:Rate Your Marriage At This Time (Wife) On Life Support Lousy Could Be Better Surviving Good Could Be Better Thriving What are you expecting from us? (Wife)How were you referred to the Marriage Coaching Ministry?Privacy Statement All personal information collected by ECRC Marriage Coaching Ministry will be held in the strictest of confidence. Contact and personal information will only be used to assist with the Marriage Coaching process and send information to you. Δ
