Couples 8 Week Course Form - for Wives

Full Name(Required)

Participant Age(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address City State ZIP Code

Marital Status(Required)

Yes

How Long Have you Been Married?

Do you have children?(Required)

Yes

How many & what are their ages?

Please describe the history of your husband’s sexual sin, including first discovery and where he is today:

Please describe the current status of your relationship with your spouse:

On a scale of 1 to 10, 10 being best, please rate your level of trust in your husband:

Has your husband taken full responsibility for his acts, or does he blame you?

Please describe your efforts to date in searching for healing and help (groups, counseling, etc):

Have you or your husband ever been molested or abused?

Are you on any medication? If so please list the prescriptions and diagnosis.

Are you having any suicidal thoughts?

Has your husband ever hit you or abused you in some other way?

Have you or your husband had any exposure to or been involved with occult activities?

Name 3 things you would like your husband to be able to provide/do for you that would be a big blessing to you:

What do you see as your husband’s greatest need for healing?

Describe your family of origin:

What is your relationship with the Lord like?

When is the last time you had at least one hour of silence with the Lord, alone?

What would you say is your greatest need and/or how we could help you the most?

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Couples 8 Week Course Form – for Wives