Couples Questionnaire OnCourse Couples Survey All responses will be held in confidence by OnCourse International. * Indicates REQUIRED field.Please complete the entire form to ensure prompt and accurate processing. Your Name:*Age:*Your confidential email address:* Marital Status:*- Select -MarriedSingleSeparatedDivorcedWidowedPhone - Work:Phone - Home:Phone - Mobile:City:State / Province:Postal Code:Country:Partner's Name:Names & Ages of Children:Please enter a number from 1 to 100.Please enter a number from 1 to 100.Please enter a number from 1 to 100.Please enter a number from 1 to 100.Please enter a number from 1 to 100.Please enter a number from 1 to 100.Number of times previously married; length of relationship; reasons for breakup (if applicable):Children from previous mariages(s); their living situation (if applicable):Describe your vocational situation:Your Current PartnerHow long have you been with your current partner?(Years)What first attracted you to your partner?Describe your relationship with your partner:How would you like the relationship to change?Describe the dynamics (agreements, synergies, disagreements) in your relationship related to:Power / Control / Conflict:Money:Sex:Having and raising children:Extended Family (parents, in-laws, siblings):Spirituality:Describe the intimacy in your relationship. What do you want? What blocks intimacy?Please comment on any other significant elements or issues of your relationship with your current partner, not covered above:Children (please answer all applicable questions)How much time do you spend with your children in an average week?(hours)What values are you committed to passing on to your children?What habits / behaviors / patterns of yours may have a negative influence on your children?What habits / behaviors / patterns of your current partner may have a negative influence on your children?(If divorced or separated) What elements of your relationship situation with your ex-partner may have a negative influence on your children?Please comment on any other significant elements or issues of your relationship with your children, not covered above.About Your Family BackgroundDescribe the atmosphere at home when you were a child (e.g., playful, tense, fighting, loving, worried, contracted, controlling, abusive, dad-always-gone, other):Describe your relationship with each of your parents / step-parents when you were growing up:Describe your parents' marriage when you were growing up:How did your parents express love to one another? To you?Describe your current relationship with each of your parents / step-parents:Describe any taboos or family secrets that were not to be discussed:Please comment on any other significant elements or issues of your relationship with your extended family (parents, step-parents, siblings, others), not covered above.Spiritual PracticeDescribe your individual spiritual beliefs / practices:What spiritual beliefs / practices do you share with your partner? Where do you and your partner differ in your spiritual beliefs / practices?If You Are Attending a Relationship Retreat with UsWhat is missing in your life that is very important to you?When you depart on the final day of the retreat, how will you know the retreat has been valuable for you?Confidentiality Notice:A copy of your submitted questionnaire will be sent to you at the email address you provide in the following field. You may leave this field blank if you do not wish to receive a copy of the completed questionnaire. Please verify you are human: This iframe contains the logic required to handle Ajax powered Gravity Forms.
