Marriage Counseling Form (Husbands)

Your name *

Last name

Email address *

Phone Number

Phone type

MobileHomeWorkOther

Address

HomeWorkOther

Country

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Occupation

Age

How long have you been married?

Do you attend CCO

yes

no

Do you attend church together?

yes

no

How long have you known Jesus as your Lord & Savior?

Do you attend a Home Fellowship? Together?

Do you pray together?

yes

no

Do you read God's word together?

yes

no

Are you currently serving in any ministries? Which ones?

Have you ever been divorced? How long ago?

Do you have any children? Ages?

Have you, or are you seeing another Counselor or Therapist?

yes

no

Do you want to save your marriage?

yes

no

Are you willing to work through the process, even when it's difficult?

yes

no

Do you agree to do the assignments given? Giving them priority?

yes

no

Please explain why you are seeking counseling:

Submit

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