Couples Group Registration Form

Basic Information

Please provide your information below:

Select your preferred start date:(Required)

April 11, 2026

June 6, 2026

September 12, 2026

November 7, 2026

Your Name(Required)

Your Partners Name(Required)

Email(Required)

Phone(Required)

Relationship Information

How long have you been together?(Required)

How long have you been married (if applicable)?

Do you have children?(Required)

Yes

If yes, how many and what are their ages?

Current Challenges

What would you say is the main issue or concern in your relationship right now?(Required)

How long has this been a challenge?(Required)

Communication Insight

One thing I wish my partner understood about me is(Required)

What I’m really feeling or needing is (skip if unknown)

Goals

What are you hoping to gain from this experience?(Required)

If this group were successful for you, what would be different in your relationship afterward?(Required)

Safety & Background

Are there any concerns related to emotional or physical safety in your relationship?(Required)

Has there been any recent infidelity or major breach of trust?(Required)

Practical Information

Do you have any food allergies or dietary restrictions?(Required)

Are both partners willing and able to attend all sessions?(Required)

Yes

Anything else you would like me to know? (optional)

Couples Group Registration Form

Basic Information

Relationship Information

Current Challenges

Communication Insight

Goals

Safety & Background

Practical Information

Relationship Counselling

Group Couples Counselling

Infidelity Counselling

Addictions Counselling

General Counselling

Divorce Counselling

Parenting Counselling