Married Couples Questionnaire

The Marriage Ministry at Mariners church is committed to helping you with your current needs. To help us better understand your present concerns related to your marriage please fill out this questionnaire. All responses will be kept confidential within the leadership of the Marriage Ministry.

  1. Personal Information:Date:

Your Name:
Address:
Street / City / State / Zip
Phone: / Home: / Cell: / Work:
Email:
Spouse’s Name:
Address:
Street / City / State / Zip
Phone: / Home: / Cell: / Work:
Email:
  1. Family Information:

How long
have you
been married? / Number of
previous marriages? / Number of children
from current marriage / Number of children from previous marriage
Ages and gender of children
Where are children currently living?
  1. Reasons for Seeking Help:

(Type in highlighted areas. For all answers below, feel free to enter as much information as needed – the field will expand)

Describe what you believe to be the key problem(s) in your marriage.
Describe what you believe your spouse would say are the key problems in your marriage.
  • When did you begin to see conflicts/problems?

What have you done in the past to get help for your marriage? (Counseling, seminars, workshops) and when did you do this?
  1. Physical & Psychological History:

Are you currently experiencing any physical difficulties?
Are you currently taking medication?
Are either of you misusing drugs or alcohol? If yes, describe to what extent.
  • Have either of you been diagnosed with depression or any other mental illness? If yes, please describe.

Has there been any abuse either past or present in your marriage? Physical Sexual Emotional
Please describe.
  1. Spiritual History:

Briefly describe your spiritual journey.
  • Have you accepted Christ as your personal Savior? If so, briefly describe.

Do you believe your spouse is a Christian?
Describe your understanding of God’s design for your marriage?
How would you describe your level of commitment to God’s purposes for your life?
Do you have others in your life to help encourage you in your faith and in your marriage?
Describe your desire and willingness to meet with another coaching couple for a marriage assessment.
Are you willing to participate in a Christ-centered workshop or small group where you and your spouse may face some uncomfortable areas in your relationship?
Is there anything else you feel we should know?
Are you currently attending Mariners or another church?

Please email completed questionnaire to:

Attention: Rob & Roxanne Maroney, Directors of Marriage Ministry

All responses are treated confidentially

Marriage Ministry – Mariners Church