Pre-Marital Counseling Form
Personal & Confidential
General Information
Name: ________________________________________ Birthdate: ________________
Address: __________________________________________ Age: ________________
Home Phone: ______________ Bus. Phone: ________________ Cell: ______________
Marital Status:
____Never been married
____Separated, since ____
____Divorced, since ____
____Widowed, since____
Number of previous marriages ____
Number of times previously engaged ____
Occupation: _______________________________ Years at that job: _______________
Employer: ________________________; Address: ______________________________
Education/Degree: (1) ______________(2)________________ (3)__________________
Other Training: ___________________________________________________________
Military Experience ___________________________________ For how long?_______
Dating History
How did you meet? _______________________________________________________
How long have you known each other? ________________________________________
How long have you dated? __________________________________________________
How soon do you plan to be married? _________________________________________
Did you date others prior to meeting? (1) For how long?______(2) For how long?______
Have you been previously engaged, though not married, to someone else? Yes __/ No __
Health
Describe your general health: Excellent __; Very Good __; Good __; Avg. __; Poor ___
Describe all important present and past illnesses or handicaps:
When was your last physical exam? _____________ Results: _____________________
Are you presently taking medication? Yes ___. No ___.
If “Yes”, what type and for what purpose:________________________________
__________________________________________________________________
Have you seen (yes __; no ___) or are you presently seeing (yes __; no ___) a mental
health professional? Regarding: addiction __; depression __; anxiety __; relational ___.
Personal Attributes
Positive Traits: ___________________________________________________________
________________________________________________________________________
________________________________________________________________________
Negative Traits: __________________________________________________________
________________________________________________________________________
________________________________________________________________________
Family History
Father’s Name ___________________________ Living ? Yes __ / No __ ; Age _____
Occupation _______________________Education (highest level completed)__________
Marital Status: Married __ ; Divorced ___ ; Separated ___ ; Widowed ___
Father’s positive traits: _____________________________________________________
________________________________________________________________________
Father’s negative traits: ___________________________________________________
________________________________________________________________________
Mother’s Name __________________________ Living ? Yes __ / No __ ; Age _____
Occupation _______________________Education (highest level completed)__________
Marital Status: Married __ ; Divorced ___ ; Separated ___ ; Widowed ___
Mother’s positive traits: ___________________________________________________
________________________________________________________________________
Mother’s negative traits: ___________________________________________________
________________________________________________________________________
Describe your parents’ relationship with each other:
Friendship
1
2
3
4
5 (highest)
Intimacy
1
2
3
4
5 (highest)
Communication
1
2
3
4
5 (highest)
Co-management (eg. chores, finances etc.)
1
2
3
4
5 (highest)
What qualities in your parents’ relationship would you like to duplicate in your marriage?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What qualities in your parents’ relationship would you NOT like to duplicate in yours?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Describe any major crises in your parents’ relationship:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Siblings: # of brothers ____; # of sisters ______.
Where do you fit in the birth order? ______
How many of your brothers are married? ___ separated ? ___
How many of your sisters are married? _____ separated ? ___
divorced ? ___
divorced ? ___
Are there any patterns of physical or mental/emotional health issues in your family?
If so, please describe: _____________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Children:
Are there any children from previous relationships / marriages? List with age(s)
indicating whether they presently live with you:
(1)
(2)
(3)
(4)
__________________________________ Age ________ Lives with _________________________
__________________________________ Age ________ Lives with _________________________
___________________________________ Age ________ Lives with _________________________
___________________________________ Age ________ Lives with _________________________
(use additional space on back if necessary)
Goals and Values
List 5 goals in order of importance that your are seeking to achieve in your lifetime:
(1)__________________________________________
(2)__________________________________________
(3)__________________________________________
(4)__________________________________________
(5)__________________________________________
List 5 things that you value greatly:
(1)__________________________________________
(2)__________________________________________
(3)__________________________________________
(4)__________________________________________
(5)__________________________________________
Please describe your religious background (from childhood…parents) and where you
stand today regarding your religious or spiritual affiliations, beliefs and commitments:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Marriage
Why are you getting married?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What do you expect of your mate in marriage?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What will you expect to give to your mate in marriage?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Describe what you believe to be the husband’s role in marriage.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Describe what you believe to be the wife’s role in marriage.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Indicate which of the following might be issues worth discussing in pre-marital
counseling:
__ communications
__ finances
__ where we plan to live
__ past relationships
__ parents (in-laws)
__ parents (my own)
__ intimacy/sex
__ children (existing)
__ children (giving birth)
__ spiritual status and/or growth
__ where we will worship
__ friends
__ occupations
__ long term goals
__ our wedding
__ something I’ve never told him/her