marital by admin | Jun 11, 2018 | ANWA Releases | 0 comments MARITAL INTAKE Phone Name * address * Preferred Phone Number Email Address * In Case of Emergency Contact * Emergency Contact Number * Emergency Contact Relationship * Gender * Male Female Birthdate * Age Church Membership * Yes No Are you a member at ANWA (Chicago) Marital Status Married Divorced Separated Widowed How many years has this been your status? Date of Marriage Name of Spouse Is your spouse a member of ANWA? Yes No Your Spouse's Age Your Spouse’s Occupation Do You Have Kids? (If so, how many) * Is Your Spouse willing to come/commit to counseling? * Yes No Have you ever been separated or divorce? Yes No Have either of you ever filed for divorce? Yes No Give brief information about any previous marriages (if applicable): Are you currently involved in, or anticipate being involved in any litigation or legal action? If yes, please explain: Has counseling been recommended or ordered for you by an attorney, police, court, probation, or parole system? If so, please explain: Are you currently receiving or have you ever received any type of counseling, psychotherapy, psychiatric care or addiction recovery help? If yes, please indicate by noting from whom, when, for what reason and with what results? Have you ever attempted suicide? If so, when? Have you ever been hospitalized for a mental, emotional or addiction issue? If so, list when, where and why: Check all that currently or recently apply to you Sex Apart From Marriage Abuse/Neglect Divorce Counsel Separation Infidelity Financial Issues Communication Other Briefly describe the reasons for seeking counseling: Please state your goals for counseling (how you hope to benefit from counseling): I declare that this information is accurate and complete by signing my name below (Electronic Signature) * Today's Date * Submit a Comment Cancel reply Your email address will not be published. Required fields are marked *Comment Name * Email * Website Notify me of follow-up comments by email. Notify me of new posts by email. This site uses Akismet to reduce spam. Learn how your comment data is processed.