Women/Wives Counseling Questionnaire

Full Name(Required)

Participant Age(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

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?

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?

What is your relationship with the Lord like?

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

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