Couple Profile – Partner – Sizzling Hot Marriage

Partner Profile

Couple Profile - Partner

Couple ID

First Name *

Last Name *

Email *

Cell Phone *

Time Zone *

What is the best time you can be reached by phone? *

Describe the problem for which are you seeking help? *

What led up to your decision to reach out for help? *

What have you done before in attempt to fix these problems? *

What would you hope to be the outcome of this intervention? *

Symptom Checklist *

Anxiety

Depression

Anger

Concentration

Phobia

Communication

Drugs/Alcohol

Eating Disorder

Parents

Children

Sleeping

Child Abuse

Sex Abuse

Nightmare

Financial Problem

Head Injuries

Nausea

Attention

Trusting Others

Worry

Self-Inflicted Pain

Can't keep a job

STD

Neck Pain

Diabetics

High Blood Pressure

Obesity

Suicidal Thoughts/Attempts

Are you looking for us to prescribe medicine for you? *

Yes

We may recommend medication but you must see your primary physician, psychiatric nurse practitioner or psychiatrist for your prescriptions.

Are you thinking about hurting yourself or someone else? *

Yes

If you are thinking of hurting yourself or someone else you should call 911 and let them know so that you can get assistance right away.

What is your spiritual orientation? *

Standard Non Faith-Specific

Catholic Christian

Protestant or Non-Denominational Christian

Orthodox Christian

Jewish

We offer services from a Christian perspective. We pray with our clients because we believe that God is a big part of the transformation our couples experience.

We do not offer in-person sessions. Are you OK with video conferencing?

Yes

We have found that video conferencing is just as effective as face-to-face. We utilize Zoom primarily. Our in-person services are in the form of retreats and get-a-ways.

Are you ready to do something different?

Very Ready

Mostly Ready

Not Ready

Our approach to treating marital problems focuses on transformation. It includes marriage classes that gives you the knowledge you need to enjoy a great marriage.

Are you prepared to spend the time needed to work on your goals? *

Yes

Is this a good time for you to do this? If you are extremely busy with other priorities, this may not be the best time for you to focus on your marriage.

Are you prepared to cover the cost of these services? *

Yes

We do not accept insurance. We do accept health savings and flex spending accounts. Our current prices for our programs range from $500 to $12,000.

User ID

If you are human, leave this field blank.