Name * Spouses/ Fiances Name * Mailing Address * Phone * Email * How many years have you been married * Where do you attend church? * Did you complete a Free Indeed Program or are you currently enrolled? * Yes No Briefly describe the reason you are seeking marriage coaching. * Have you received marriage counseling or other help? If so, please describe. * Confidentiality Information Confidentiality and privilege communication remain rights of all participants according to state law. However, if an individual intends to take harmful, dangerous, or criminal action against another human being, or against themselves, it is the duty of Free Indeed Ministries leadership to warn appropriate individuals of such intentions. Suspected acts of child abuse or neglect are required to be reported. Those warned may include but are not limited to; the person or family of the person who is likely to suffer the results of harmful behavior; the family of the participant who intends to harm himself/herself or someone else, associates and friends of those threatened or making threats; law enforcement officials. Before informing anyone who should be warned, Free Indeed Ministries leadership will take all possible steps to first share that intention with the participant. Every effort will be made to prevent any such breach of confidentiality. Reply to confidentiality statement * Yes No If you are human, leave this field blank. Submit
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