Phone _____________________ Business phone ____________
Occupation __________________________________________________________
Name & address of company __________________________________________
Your spouse's age ___ Education (in years)____ Religion _____________
Is spouse willing to come for counseling? Yes__ No___ Uncertain ___
Date of marriage _________
Have you ever been separated? Yes __ No __ When? From ______ to ______
Has either of you ever filed for divorce? Yes __ No __ When? ________ Your ages when married: Husband ____ Wife ____
How long did you know your spouse before marriage? __________________ Length of steady dating with spouse ________ Length of engagement ____ Give brief information about any previous marriages: __________________
_______________________________________________________________________
Information about children:
| Name | Age | Sex | Living: yes/ no | Education (years) | Adopted: yes/ no | Marital Status |
If you were reared by anyone other than your own parents, briefly explain: ______________________________________________________________
_______________________________________________________________________
How many older brothers _____ sisters _____ do you have?
How many younger brothers _____ sisters ____ do you have?
Have there been any deaths in the family during the last year?
Yes ___ No ___
Who and When: _________________________________________________________________________
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