Why you getting help from a provider?—Please choose an option—Improve our communicationDecide whether we should seperateResolve conflicts and disagreementsUnderstand myself betterUnderstand my partner betterGet to a more fair workloadReduce tensionPrevent separation or divorceLearn good ways to fightStop hurting each otherLove my partner againDiscuss issues around raising kidsDivorce or separation mediation
I'm looking for a provider that will...—Please choose an option—Teach new skillsAssign homework and tasksChallenge illogical beliefsExplore past experiencesTeach mindfulnessActively listenExplore personal meaning to experiencesInstill hopeCollaborateNot sure
Have you worked with a couples counselor?—Please choose an option—YesNo
Do you currently live with your partner?—Please choose an option—YesNo
Is domestic violence an issue in your relationship?—Please choose an option—YesNoSometimes
When would you be looking to get started with a counselor?—Please choose an option—We're ready nowIn the next couple of monthsNot sure yet
What gender would you prefer in a provider?—Please choose an option—No preferenceFemaleMaleI'm not sure yet
Choose your gender—Please choose an option—FemaleMale
What is your marital status?—Please choose an option—MarriedSinglePartner
How old are you?—Please choose an option—Less than 1819 - 2526 - 3031 - 3536 - 45More than 45
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