Journey Applicationfor Couples Name First Name Last Name Name * First Name Last Name Email * Phone (###) ### #### Have you done this type of work before? If yes, please describe. * Are you prepared to research, read, and prepare yourself for this kind of work? * Why are you interested in this kind of work? * How did you hear about me and this work? * What do you imagine I can help you with? * Why do you feel we would be a good fit to work together? * Do you take any medications, supplements, or herbal remedies on a regular basis? If yes, please explain. * If on prescription medication(s), which doctor do you receive these from? * Please describe your relationship to alcohol, marijuana, tobacco, or other substances. For this type of work, the accuracy of this answer is highly important. * How long have you been together in this relationship? * How would you like to improve your relationship? (Examples: Be free of burdened repetitive patterns; clearing out the past; restore trust.) * Has there been any physical or emotional abuse in your current relationship? * Has there been any physical or emotional abuse in either of your past relationships? * What are some difficult things from your familial/childhood history? Including traumatic experiences you've had, and what support (if any) have you relied on to help you integrate? * Tell me about the family you grew up in, what were things like when you were growing up? What is your relationship like with your family now? * Tell me about your support system: Friends? Family? Community? Religion/Spirituality? * What therapists/coaches/counselors have you or are you working with, specifically how long you’ve been with them and the intention of the work? * Is there anything else you'd like me to know about you, perhaps something that feels better to write about before talking about it? *
