Take your marriage to the next level,and help us get to know you better. Marriage Mediation Form Name * First Name Last Name Date of Birth: * MM DD YYYY Phone * (###) ### #### Email * Occupation: * What is your address? * How many years have you been married? * Are you currently living together? * Are there any children living at home? * If so, how many? Please describe why you believe your marriage is struggling: * Please list your top three issues (communication, intimacy, trust, finances, priorities, etc.): * What are your goals/hopes for your mediation session? * How does God/faith play a role in your marriage? * Are you personally struggling with grief, deep emotional pain, unresolved resentment, and/or unforgiveness? * Are you currently taking any medications? * Yes No If so, please list any medications: Do you feel you and your spouse are on the same page regarding mediation/wanting to better your marriage? Yes No Are there any current (or within the past 3 months) any addictions, affairs, or abuse? No Not within the last 3 months Yes Thank you!