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About
Marriage Retreats
Considering Divorce
Issues Treated
Testimonials
Blog
- Publications & Professional Citations
Contact Us

About
Marriage Retreats
Considering Divorce
Issues Treated
Testimonials
Blog
- Publications & Professional Citations
Contact Us

Consultation Questionnaire

Please answer the questions below in order to make your consultation as effective as possible. Thank you, and I look forward to speaking with you soon.

Consultation Questionnaire

Your Preferred First Name *

Your Last Name *

Partner’s Preferred First Name *

Partner’s Last Name *

Would your partner like to complete their own form?

Yes, please send them a link.

No, we’re completing this form together.

No, I’m completing this form alone.

They already submitted their form

What is your partner’s email address? Please make sure to get permission from them first.

Where do you live? Where do you live?

Current Relationship Status

Married

Engaged

Dating

Divorced

How many years have you been dating?

How many years have you been married?

Do you have any kids?

Yes, with my current partner.

Yes, with a previous partner.

No, but my partner does.

No, neither of us do.

How old are your kids?

How seriously are YOU considering divorce or separation right now?

How seriously do you think YOUR PARTNER is considering divorce or separation right now?

How significantly do you think your’s or your partner’s past trauma or wounds currently impact the relationship?

How concerned are you about the impact of substance use on your relationship?

What are your current relationship concerns?

Communication Issues

Poor Emotional Regulation

Feeling Unprioritized

Low Intimacy

Sexless Marriage

Resentment

Infidelity or Affair

OtherOther

Select all that apply

Is there anything else you want me to know before our consultation?

0 of 500 max characters

Please note that information collected with this form may not be secure. Submitting this form also doesn’t not create a doctor-patient relationship. By submitting this form, you agree to the terms in our privacy policy.

If you are human, leave this field blank.

Want To Learn More?

Please review our website for more information about a marriage counseling retreat. You can also read through our blog for helpful tips.

Learn More About Retreats

Review Our Blog

You and your spouse deserve a fulfilling and peaceful marriage.

MAIN OFFICE

Marriage Quest
190 Eastern Ave, Suite 206B
St Johnsbury, VT 05819
United States

(802) 212 – 3123
Contact Us Now

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No Surprise Act

ISSUES TREATED

Heartbroken & Considering Divorce
Sexless Marriage
Midlife Crisis & Marriage
Couples Communication
Infidelity & Emotional Affairs
Resentment In Marriage

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Partial funding for development of this website made possible by a Rural Business Development Grant to Northern Community Investment Capital from USDA Rural Development.

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