Premarital Counseling
Pre-Counseling Questionnaire
To my new friends:
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You have received this questionnaire because you have asked me to perform your premarital counseling (and perhaps your wedding as well), and because I want to offer you the best premarital counseling that I am able to offer.
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I realize that I do not know you well— not yet! I trust that during counseling I will get to know you much better. However, for me to counsel you well from the start, I need to ask about who you both are, what your backgrounds are, what work is like for you, what your family was like growing up, and other things about you and your past. Many of these questions are very personal; in fact, some of them may touch on things that you have not yet spoken about openly even with your fiancé.
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Please trust that your completed questionnaire will not be shared with anyone else; I will not use this information against you; and I am not looking for ways to judge you or make you feel awkward or ashamed. And please also trust that I, and many who are wiser than I am, have concluded that these topics are very important factors in how healthy your marriage will be. I simply want to work with you to lay the foundations for the healthiest marriage possible.
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About the couple
General Information:
How long have you known each other?
______________________________________________________________________
How long have you been dating?
______________________________________________________________________
How long have you been engaged?
______________________________________________________________________
What is the anticipated date of your wedding?
______________________________________________________________________
Are you currently living together? !!

☐ No!!

☐ Yes

Are you currently sexually active? !

☐ No!!

☐ Yes

Counseling Information:
Which of the following time-slots best suits BOTH of you for pre-marital counseling sessions?
(Circle all that apply)
Days! !

!

!

!

!

!

Times

Monday !

Tuesday !

!

!

!

Early morning!

Morning

Wednesday! Thursday!

!

!

!

Mid-day !

Afternoon

Friday !

!

!

!

Late afternoon!

Saturday!

!

Evening

About the bride
Personal Information:
Name:!!

___________________________________________________________

Phone(s):!

___________________________________________________________

E-mail:!

___________________________________________________________

Date of Birth! ___ / ___ / ______
Where you grew up: !

________________________________________________

Where you live now:!

________________________________________________

Education Level (check highest completed):
☐ High School
☐ Some college
☐ College graduate
☐ Some graduate school
☐ Completed graduate school
☐ Other ( ___________________________________________________ )
Health Information:
Rate your current health (check only one):
☐ Very Good
☐ Good
☐ Average
☐ Poor
Date of last medical exam: ___ / ___
Report: !

___________________________________________________________

______________________________________________________________________
Are you currently taking medication? !
!

☐ No!!

☐ Yes

(If yes, which ones: !________________________________________________)

Please list any current or recent illnesses, injuries, or other handicaps:
______________________________________________________________________
______________________________________________________________________
Your approximate weight ______ lbs.
!

Weight changes recently: Lost ___________! Gained ___________

Faith/Beliefs Information:
My current church/faith circumstances (check all that apply):
☐ I currently attend a church. (which one? ______________________________ )
☐ I am a member of a church. (which one? ______________________________ )
☐ I attend worship on Sundays nearly every week.
☐ I attend worship on Sundays several times a month.
☐ I attend worship on Sundays once or twice a month.
☐ I attend worship on Sundays several times a year.
☐ I attend worship on special days through the year (Christmas, Easter, etc.).
☐ I am actively involved in other parts of my churchʼs life besides Sunday morning worship. ☐ I do not currently attend any church.
My church/faith background (check all that apply):
☐ I have never attended a Christian church.
☐ I am uninterested in matters of faith as they relate to me, my wedding, or my marriage.
☐ I am interested in learning more about Christianity and the church, and how they relate to me, my wedding, and my marriage.
☐ I grew up attending a Christian church. (which denomination?
_________________________ )
☐ I grew up in a family environment that was indifferent to religion and Christianity.
☐ I grew up in a family environment that was hostile to religion and Christianity.
☐ I began attending church after childhood. (when: _____________________________ )
☐ I have made a profession of faith in Jesus Christ. (when: ___ / ___ )
Family Information:
My parent(s) were/are (check all that apply):
☐ married all of my life.
☐ still married.
☐ separated but never divorced.
☐ divorced...
☐ during my childhood.
☐ after my adulthood.
☐ mom remarried...
☐ during my childhood.
☐ after my adulthood.

☐ dad remarried...
☐ during my childhood.
☐ after my adulthood.
☐ single parents.
☐ mother is deceased.

!

(when: ___ / ___ )

☐ father is deceased.

!

(when: ___ / ___ )

☐ I grew up in the foster-care system.
☐ I was adopted.

About my siblings (list each):
!

________________________!

☐ younger ☐ older ☐ full ☐ half ☐ step

!

________________________!

☐ younger ☐ older ☐ full ☐ half ☐ step

!

________________________!

☐ younger ☐ older ☐ full ☐ half ☐ step

!

________________________!

☐ younger ☐ older ☐ full ☐ half ☐ step

!

________________________!

☐ younger ☐ older ☐ full ☐ half ☐ step

!

________________________!

☐ younger ☐ older ☐ full ☐ half ☐ step

My marriage experience and background (check all that apply):
☐ Iʼve never been married.
☐ Iʼve never married before, but I have lived with a partner before.
☐ I have been previously engaged but not married.
☐ Iʼve been married before. (how many times? ____)
☐ I was divorced. (when ___ / ___ )
☐ I was widowed. (when ___ / ___ )
My parenting experience and background (check all that apply):
☐ I am pregnant now.
☐ I have been pregnant before…
☐ I have _____ children...
☐ and I miscarried.
☐ as a single parent.
☐ and I had an abortion.
☐ from a previous marriage.
☐ and I gave my child up for
☐ with my current partner/fiancé. adoption. ☐ My children...
☐ live with me all the time.
☐ split time with me and their father.
☐ live with their father all the time.
☐ are cared for by someone else.
(who?
_______________________ )
Work Information:
Current job: ________________________________________
Does your job require you to travel?
☐ No
☐ Yes— If yes, how many days/nights do you travel per month?
!
!
_____ days/nights (circle one) per week/month (circle one)
Have you ever been suddenly fired from a job? (When: ___ / ___ )
Have you ever done any of the following as a part of your work? (check all that apply):
☐ worked in law enforcement
☐ served in the military
☐ served in combat
☐ worked in a hospital, in crisis counseling, or some other circumstance in which you were regularly exposed to high levels of trauma
☐ worked in politics
☐ as a politician/candidate
☐ as support staff for a politician/candidate

Work Information, Continued…:
Which of the following best describes your average work-week?
☐ I do not work outside of the home.
☐ I work less than 20 hours a week.
☐ I work 20-30 hours a week.
☐ I work 30-40 hours a week.
☐ I work 40-50 hours a week.
☐ I work 50-60 hours a week.
☐ I work more than 60 hours a week.
Emotional/Counseling-Related Information:
In addition to your excitement, describe your feelings about your upcoming marriage:
☐ I donʼt want to give up the freedom

☐ I am worried that my fiancé and I

and fun of singleness.
☐ I canʼt wait to have a husband who

will be my constant companion.
☐ I feel pressured/required to get

☐
☐

married.
☐ I am concerned about my

☐

relationship with my future in-laws.
☐ I believe that my future in-laws will

meet some of my relational needs in ways that others cannot.

☐

donʼt think the same way about money and financial matters.
I canʼt wait to have children.
I am not certain that I want children. I know for sure that I do not want to have any (or any more) children. I am afraid that my fiancé doesnʼt share my thoughts about children.

My counseling background and experience (check all that apply):
☐ I am currently taking medication to treat a clinical emotional/psychological diagnosis.
(Prescribing Doctor/Psychiatristʼs name: _______________________)
☐ I have seen a professional counselor before.
☐ I am working with a professional counselor now.
!
!
(Who— name & practice: ______________________________________)
My substance abuse background (check all that apply):
☐ I have the following relationship(s) to alcoholism and/or addiction (check all that apply):
☐ One or both of my parents were/are alcoholics.
☐ One or both of my parents were/are addicted to some other substance.
☐ Some other family member was/is an alcoholic.
☐ Some other family member was/is an addict.
☐ A previous boyfriend/partner/spouse was an alcoholic.
☐ A previous boyfriend/partner/spouse was an addict.
☐ I am a recovering alcoholic.
☐ I am a recovering addict.
☐ I am an alcoholic (but I am not currently pursuing recovery).
☐ I am an addict (but I am not currently pursuing recovery).

My social/emotional/relational background and struggles (check all that apply):
☐ I have difficulty relating to others.
☐ I have recently suffered the loss of

!

someone close to me. (Who & when: _____________________)
☐ I was raped. When & by whom:
__________________________)
☐ I was abused by a parent growing up. ☐ verbal/emotional abuse
☐ physical abuse
☐ sexual abuse
☐ I was abused by someone else growing up.
(Who?_____________________ )
☐ verbal/emotional abuse
☐ physical abuse
☐ sexual abuse

☐ I have been in ____ number of

!

abusive relationships as an adult.
(Who?_____________________ )
☐ verbal/emotional abuse
☐ physical abuse
☐ sexual abuse
☐ Other (__________________)
☐ I have been arrested.
☐ I have been diagnosed with...
☐ depression.
☐ anxiety.
☐ an eating disorder. (which one
(s): ____________________ )
☐ a personality disorder. (which one(s): _________________ )

About This Information:
☐ I have discussed all of the above with my fiancé, and I am comfortable discussing these

issues as a part of premarital counseling.
☐ I have NOT discussed all of the above with my fiancé; I will communicate with you about

how and when we might introduce these topics in premarital counseling. (Please indicate with an asterisk (*) which topics you have not discussed with your fiancé.)
If you are currently seeing another professional counselor and/or medical professional:
☐ I am willing to sign a release so that the Pastor may discuss my circumstances and

premarital counseling with my other counselor(s) and/or doctor(s).
☐ I am NOT willing to sign a release so that the Pastor may discuss my circumstances and

premarital counseling with my other counselor(s) and/or doctor(s).
By completing this questionnaire (and signing below), I commit to working with the Pastor to fulfill all of the requirements of pre-marital counseling, including reading, worksheets, workbooks, and counseling sessions, to the best of my ability.

Signed: ___________________________________________ Date ___ / ___ / ______

About the groom
Personal Information:
Name:!!

___________________________________________________________

Phone(s):!

___________________________________________________________

E-mail:!

___________________________________________________________

Date of Birth! ___ / ___ / ______
Where you grew up: !

________________________________________________

Where you live now:!

________________________________________________

Education Level (check highest completed):
☐ High School
☐ Some college
☐ College graduate
☐ Some graduate school
☐ Completed graduate school
☐ Other ( ___________________________________________________ )
Health Information:
Rate your current health (check only one):
☐ Very Good
☐ Good
☐ Average
☐ Poor
Date of last medical exam: ___ / ___
Report: !

___________________________________________________________

______________________________________________________________________
Are you currently taking medication? !
!

☐ No!!

☐ Yes

(If yes, which ones: !________________________________________________)

Please list any current or recent illnesses, injuries, or other handicaps:
______________________________________________________________________
______________________________________________________________________
Your approximate weight ______ lbs.
!

Weight changes recently: Lost ___________! Gained ___________

Faith/Beliefs Information:
My current church/faith circumstances (check all that apply):
☐ I currently attend a church. (which one? ______________________________ )
☐ I am a member of a church. (which one? ______________________________ )
☐ I attend worship on Sundays nearly every week.
☐ I attend worship on Sundays several times a month.
☐ I attend worship on Sundays once or twice a month.
☐ I attend worship on Sundays several times a year.
☐ I attend worship on special days through the year (Christmas, Easter, etc.).
☐ I am actively involved in other parts of my churchʼs life besides Sunday morning worship. ☐ I do not currently attend any church.
My church/faith background (check all that apply):
☐ I have never attended a Christian church.
☐ I am uninterested in matters of faith as they relate to me, my wedding, or my marriage.
☐ I am interested in learning more about Christianity and the church, and how they relate to me, my wedding, and my marriage.
☐ I grew up attending a Christian church. (which denomination?
_________________________ )
☐ I grew up in a family environment that was indifferent to religion and Christianity.
☐ I grew up in a family environment that was hostile to religion and Christianity.
☐ I began attending church after childhood. (when: ______________________________ )
☐ I have made a profession of faith in Jesus Christ. (when: ___ / ___ )
Family Information:
My parent(s) were/are (check all that apply):
☐ married all of my life.
☐ still married.
☐ separated but never divorced.
☐ divorced...
☐ during my childhood.
☐ after my adulthood.
☐ mom remarried...
☐ during my childhood.
☐ after my adulthood.

☐ dad remarried...
☐ during my childhood.
☐ after my adulthood.
☐ single parents.
☐ mother is deceased.

!

(when: ___ / ___ )

☐ father is deceased.

!

(when: ___ / ___ )

☐ I grew up in the foster-care system.
☐ I was adopted.

About my siblings (list each):
!

________________________!

☐ younger ☐ older ☐ full ☐ half ☐ step

!

________________________!

☐ younger ☐ older ☐ full ☐ half ☐ step

!

________________________!

☐ younger ☐ older ☐ full ☐ half ☐ step

!

________________________!

☐ younger ☐ older ☐ full ☐ half ☐ step

!

________________________!

☐ younger ☐ older ☐ full ☐ half ☐ step

!

________________________!

☐ younger ☐ older ☐ full ☐ half ☐ step

My marriage experience and background (check all that apply):
☐ Iʼve never been married.
☐ Iʼve never married before, but I have lived with a partner before.
☐ I have been previously engaged but not married.
☐ Iʼve been married before. (how many times? ____)
☐ I was divorced. (when ___ / ___ )
☐ I was widowed. (when ___ / ___ )
My parenting experience and background (check all that apply):
☐ A partner of mine has been
☐ My children...
☐ live with me all the time. pregnant before…
☐ and she miscarried.
☐ split time with me and their
☐ and she had an abortion. mother. ☐ I have _____ children...
☐ live with their mother all the
☐ as a single parent. time. ☐ from a previous marriage.
☐ are cared for by someone else.
☐ with my current partner/fiancé.
(who? __________________ )
Work Information:
Current job: ________________________________________
Does your job require you to travel?
☐ No
☐ Yes— If yes, how many days/nights do you travel per month?
!
!
_____ days/nights (circle one) per week/month (circle one)
Have you ever been suddenly fired from a job? (When: ___ / ___ )
Have you ever done any of the following as a part of your work? (check all that apply):
☐ worked in law enforcement
☐ served in the military
☐ served in combat
☐ worked in a hospital, in crisis counseling, or some other circumstance in which you were regularly exposed to high levels of trauma
☐ worked in politics
☐ as a politician/candidate
☐ as support staff for a politician/candidate

Work Information, Continued…:
Which of the following best describes your average work-week?
☐ I do not work outside of the home.
☐ I work less than 20 hours a week.
☐ I work 20-30 hours a week.
☐ I work 30-40 hours a week.
☐ I work 40-50 hours a week.
☐ I work 50-60 hours a week.
☐ I work more than 60 hours a week.
Emotional/Counseling-Related Information:
In addition to your excitement, describe your feelings about your upcoming marriage:
☐ I donʼt want to give up the freedom

☐ I am worried that my fiancé and I

and fun of singleness.
☐ I canʼt wait to have a husband who

will be my constant companion.
☐ I feel pressured/required to get

☐
☐

married.
☐ I am concerned about my

☐

relationship with my future in-laws.
☐ I believe that my future in-laws will

meet some of my relational needs in ways that others cannot.

☐

donʼt think the same way about money and financial matters.
I canʼt wait to have children.
I am not certain that I want children. I know for sure that I do not want to have any (or any more) children. I am afraid that my fiancé doesnʼt share my thoughts about children.

My counseling background and experience (check all that apply):
☐ I am currently taking medication to treat a clinical emotional/psychological diagnosis.
(Prescribing Doctor/Psychiatristʼs name: _______________________)
☐ I have seen a professional counselor before.
☐ I am working with a professional counselor now.
!
!
(Who— name & practice: ______________________________________)
My substance abuse background (check all that apply):
☐ I have the following relationship(s) to alcoholism and/or addiction (check all that apply):
☐ One or both of my parents were/are alcoholics.
☐ One or both of my parents were/are addicted to some other substance.
☐ Some other family member was/is an alcoholic.
☐ Some other family member was/is an addict.
☐ A previous boyfriend/partner/spouse was an alcoholic.
☐ A previous boyfriend/partner/spouse was an addict.
☐ I am a recovering alcoholic.
☐ I am a recovering addict.
☐ I am an alcoholic (but I am not currently pursuing recovery).
☐ I am an addict (but I am not currently pursuing recovery).

My social/emotional/relational background and struggles (check all that apply):
☐ I have difficulty relating to others.
☐ I have recently suffered the loss of

!

someone close to me. (Who & when: _____________________)
☐ I was abused by a parent growing up. ☐ verbal/emotional abuse
☐ physical abuse
☐ sexual abuse
☐ I was abused by someone else growing up.
(Who?_____________________ )
☐ verbal/emotional abuse
☐ physical abuse
☐ sexual abuse

☐ I have been in ____ number of

!

abusive relationships as an adult.
(Who?_____________________ )
☐ verbal/emotional abuse
☐ physical abuse
☐ sexual abuse
☐ Other (__________________)
☐ I have been arrested.
☐ I have been diagnosed with...
☐ depression.
☐ anxiety.
☐ an eating disorder. (which one
(s): ____________________ )
☐ a personality disorder. (which one(s): _________________ )

About This Information:
☐ I have discussed all of the above with my fiancé, and I am comfortable discussing these

issues as a part of premarital counseling.
☐ I have NOT discussed all of the above with my fiancé; I will communicate with you about

how and when we might introduce these topics in premarital counseling. (Please indicate with an asterisk (*) which topics you have not discussed with your fiancé.)
If you are currently seeing another professional counselor and/or medical professional:
☐ I am willing to sign a release so that the Pastor may discuss my circumstances and

premarital counseling with my other counselor(s) and/or doctor(s).
☐ I am NOT willing to sign a release so that the Pastor may discuss my circumstances and

premarital counseling with my other counselor(s) and/or doctor(s).
By completing this questionnaire (and signing below), I commit to working with the Pastor to fulfill all of the requirements of pre-marital counseling, including reading, worksheets, workbooks, and counseling sessions, to the best of my ability.

Signed: ___________________________________________ Date ___ / ___ / ______