Live Fully Engaged Ministries » Couples Form

Couples Form

General Information

Your Name(required)
Address(required)
City(required)
State
Zip code
Phone - Home(required)
Phone - Cell(required)
Phone - Work(required)
Fax
Email
Marital Status
Single Married Separated Divorced Widowed
If married, how many years?
If divorced, how many years?
Have you ever been in counseling? If yes when?
Are you now in counseling? If yes how long?
With whom are you counseling?
If you were referred, by whom?
Briefly describe what you would like to accomplish in counseling:
Husband:
Wife:
Briefly describe your original family
Husband:
Wife:

Do you regularly use legal or illegal medications? Alcohol?

Husband:
Yes No
Wife:
Yes No
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

Signature
Date
Human Verification

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LFEM is a 501(c)(3) charity registered with the IRS. All donations are tax deductible.

Contact Us:

Email us at: info@lfem.org
Fax us at: (888) 431-4893
Write to us at: Live Fully Engaged Ministries (LFEM)
PO Box 26452 Colorado Springs, CO 80936