Relationship Information

Relationship Information Form
  1. (required)
  2. (valid email required)
  11. Have you ever been to counseling as a result of problems with this relationship or as an individual, prior to today?
  14. Do you love your partner?
  16. Are you "in love" with them?
  18. Have either of you been unfaithful?
  20. If so, who?
  22. Have either of you been involved in pornography in the past year?
  24. Have either of you threatened to end the relationship as a result of current problems?
  26. Have either you or your partner consulted with a lawyer about divorce?
  28. If yes, who?
  30. Do you perceive that either you or your partner has withdrawn from the relationship?
  32. If yes, which of you has withdrawn?
  36. Do you feel safe in your relationship?
  39. At times do you feel trapped, helpless or powerless in your relationship?
  42. Check topics that are of concern to you and your relationship.








  46. Captcha
 

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