Discernment Counseling Intake Form | Discernment Counseling, Coaching & Private Retreats for Couples on the Brink

Discernment Counseling Intake Questionnaire

Please take a few quiet minutes (plan for 15-20) by yourself to complete this form, at least 48 hours in advance of our first joint discernment session. Please be sure to read these important notes before getting started:

Some of the questions ask how you’re feeling/thinking about your relationship. If your state of mind or heart has been in flux, just select the option that best represents where you are lately, most of the time.
If you are not legally married, just substitute whatever similarly-intentioned phrase feels appropriate for your relationship in the spots where you see the words “marriage” and “divorce”.
Please be as honest and thoughtful in your responses as possible, so that I can most effectively support you in navigating this journey with integrity, intention and from your best self.
Your specific responses to these questions (and others I will ask as we proceed) will not be shared with your partner. My role includes providing each of you with general impressions I have of both of you in this process and in the relationship, but details you share with me will be held in confidence.
This form does not have the option to save before it’s been submitted, so it will need to be done in a single session. A computer (rather than phone) will likely be easier.

Once I have received a completed questionnaire and intake form from each of you, you’ll receive the scheduling link to book your first discernment coaching session. Thanks for sharing your thoughts with me here. I look forward to getting to know you and meeting soon!

Contact details

Your Name

Pronouns

Cell phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Relationship demographics

Relationship/marital status (check all that apply)

Single

Engaged

Domestic Partners

Married

Separated

Divorced

Current living situation (check all that apply)

Living together

Separate households as usual (haven’t lived together)

In-home separation

Temporary separation (staying with friends, temporary housing, etc.)

Long-term separation (separate households)

Separated and alternating time in family home (“nesting”)

Partner/spouse’s name

Years together

Years married

Children’s names & ages (if any)

Who lives with you in your household? (Please explain blended family configurations & custody, if relevant.)

Relationship details

In answering the questions in this section, please respond with what feels accurate and generally true from where you’re sitting right now. We’ll have plenty of time when we meet to dig into the nuances and inevitable complexities as they are arise in our work together. (That is, don’t stress over it, and just make the choices that will best help me get a sense of your perspective on the relationships strengths and current challenges.)

How hopeful are you, at this point, that your marriage can be saved and rebuilt, assuming both of you work hard towards that goal?

Very hopeful

Somewhat hopeful

Not sure

Somewhat doubtful

Very doubtful

How motivated are you, at this point, to rebuild your relationship and restore it to a healthy place?

Very motivated

Somewhat motivated

Neutral

Somewhat unmotivated

Very unmotivated

Which of the following are arenas that work well for you as a couple, at least most of the time?

Which of the following are at play in your current relationship distress?

Have you tried couples therapy together?

Yes, 6 months or longer

Yes, under 6 months

Yes, just one or a few sessions

Health & Wellbeing

Are you currently working with (or are under the care of) any of the following professionals?

Individual therapist

Couples therapist

Psychiatrist

Please describe your typical use (frequency & amount) of caffeine, alcohol, nicotine, marijuana and any other recreational or self-prescribed drugs. Please use an asterisk (*) to indicate any that may be a cause of concern for you personally, and use a carat (^) to indicate any that are a source of friction in your relationship.

Please list any other habits, activities or coping strategies of yours that may be of concern to you or those close to you (e.g., gaming, shopping, porn, gambling, social media, workaholism, etc.) Please use the same symbols as above to indicate who believes this is an area of concern (* for you; ^ for your partner).

Have you ever been hospitalized for psychiatric reasons?

Yes

Have you seriously considered ending your life or someone else’s?

Yes

What are your primary coping strategies when things are difficult? How well do those work for you?

Who are your primary social supports?

What activities or hobbies in your life help replenish you? How often do you do these?

What do you see as some of your strengths or positive qualities?

Final steps

Is there anything else you’d like me to know at this point? (Please limit this to 2-3 sentences maximum.)

I understand that the purpose of discernment counseling is clarification about the next steps for my relationship and for enhanced understanding of myself and my relationship, and that this is not couples therapy intended to improve my relationship. I understand that the discernment process will include some time together as a couple, and a significant portion of the time will be 1:1 with the practitioner. I understand that my provider is not in network with any insurance companies and will not provide direct billing services. Payment is due in full at the time of service and any cancellations require 48 hours cancellation otherwise full payment is due. I may request superbills from my provider and any request for reimbursement from my insurance company is entirely between me and my insurance company. I understand that these services do not come with any guarantees, and hold Rachel Zamore, Rachel Zamore LLC, and InnerWell LLC harmless.

Signed