Couples Form

General Information
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  9. Marital Status
Do you regularly use legal or illegal medications? Alcohol?
  1. Husband:
  2. Wife:
  3. By our signatures below, we signify that we are both
    committed to keeping our appointments and working on
    our individual and marital issues. Also, we understand that it
    is required that we not bring other family members (children)
    with us to this appointment unless it is recommended by LFEM or we are
    parents and bringing our child/teen for help.
Input your full name to sign this form
 

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