EmailMe Form - Couple 2 Couple Mentoring Form

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Name *

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Spouse's Name *

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Email

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Names and ages of your children:

Names and relationships of important people in your life (excluding spouse and children):

Do you have any pets?

Education History:

Health Status:

What do you like to do in your free time?

Do you have any history or current use of drugs and/or alcohol? If yes, describe:

Is any of you seeing a therapist at this time? If yes, briefly describe reason for seeing a therapist.

Do you take any medications?

Do you practice any religion? If so, please briefly describe.

Do you have any parenting areas of concern that you would like to talk to us about?

Is there anything else you would like me to know about you or your circumstances before we begin?

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