Couples Survey Questions

Couples survey questions

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My First Name*

My Last Name*

My Email*

Partner's Name*

Counselor's Name*

If you don't have it, please input [email protected], and we will direct it to them.

My Phone*

Partner: 10-20 years vision*

Mine: 10-20 years vision*

Partner: Favorite foods*

Partner: How Do They Deal With Stress*

Mine: How Do They Deal With Stress*

Mine: What Is Their Pet Peaves*

Partner: What Do They Get Irritated About Most*

Mine: What Do They Get Irritated About Most*

Partner: Anger Level And Why (1 Weak And 10 Strong)*

Mine: Anger Level And Why (1 Weak And 10 Strong)*

Partner: What Turns Them On Romantically*

Mine: What Turns Them On Romantically*

Partner: Spiritual Maturity & Why? (1 Weak And 10 Strong)*

Mine: Spiritual Maturity & Why? (1 Weak And 10 Strong)*

Partner: Most Top 3 Traumatic Childhood Experiences*

Mine: Most Top 3 Traumatic Childhood Experiences*

Partner: Political Party Affiliation And Views*

Mine: Political Party Affiliation And Views*

Partner: Addictions/Bad Habits That Will Most Likely Affect You In Future?*

Mine: Addictions/Bad Habits That Will Most Likely Affect You In Future?*

Partner: Favorite Movies, Songs, And Books?*

Mine: Favorite Movies, Songs, And Books?*

Partner: Who Are The Most Influential People In Your Partner's Life?*

Mine: Who Are The Most Influential People In Your Partner's Life?*

Partner: What Inner Fears Are Driving Them*

Mine: What Inner Fears Are Driving You*

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"*" indicates required fields

Step 1 of 3

Step 1: Basic Information

First Name*

Last Name*

Email*

Phone*

Birthdate*

How did you learn about us?*

Name of Person Referred By

Step 3: Agreements

A. CHRISTIAN COUNSELING EXPECTATIONS

1. Christian/Biblical Counseling: Biblical Counseling, sometimes called Pastoral Counseling or Christian Counseling, has the Lord Jesus Christ as its center.

It is the counsel which:

a) Includes listening, teaching, encouraging, preparing, comforting, warning, admonishing.

c) Its purpose is to glorify God and guide the counselee into an increased understanding of his/her personal, love, grace-oriented relationship with Jesus Christ.

d) Will result in pursuing a transformed life that reflects God’s grace, glory, and joy. This type of counseling is in contrast to secular forms of counseling. Our goal is to:

“Proclaim Him, admonishing every man and teaching every man with all wisdom, that we may present every man complete in Christ. And for this purpose also I labor, striving according to His power, which mightily works within me” (Col 1:28-29).

“Equip the saints for the work of service, to the building up of the body of Christ; until we all attain to the unity of the faith, and of the knowledge of the Son of God, to a mature man, to the measure of the stature which belongs to the fullness of Christ” (Eph 4:12-13).

2. Referrals to Professionals: If you have significant legal, medical, or other technical questions, seek advice from independent professionals. Our Christian counselors will cooperate with such advisors and help you to consider their counsel in light of relevant scriptural principles.

3. Intent Listening: We encourage counselees to speak their minds appropriately and discuss thoughts, anxieties, and fears so the counselor can clearly understand core problems.

4. Assignments: Counselees progress more rapidly when they study or perform specific informational or behavioral assignments individually tailored to the problem.

5. Accountability: We desire to maximize your and the counselor’s time. One of our goals is to help believers learn how to glorify God and have the outward life reflect the yielded, godly inward life, resulting in peace and joy. Therefore, each counselee must participate actively in the counseling sessions and excercises between the sessions.

6. Length of Counseling: Biblical Counseling will vary in the amount of time required according to the individual, his/her motivation, the amount of time spent on homework, and the particular situation and/or problem. On average, Biblical Counseling requires less time than conventional, secular counseling. Simple issues may be solved in one session. Difficult situations often require a more extended period. When multiple people are involved in the counseling, more may be needed as frequently happens in marriage counseling. Substance abuse and addiction problems may require many more sessions, with intensive accountability, drug tests, and other professional help.

B. CHRISTIAN COUNSELING AGREEMENT

I/We affirm the accuracy of the personal information provided herein, have read the information above, and agree to the conditions. I now agree to the following conditions:

1. I (We) understand that the counseling I, my family, or those legally under my guardianship will receive will be based upon the Bible to glorify God and lead to a healthy, Spirit-empowered grace-filled life.

2. I (We) will keep the appointment time or will call before 72 hours to cancel. If I cancel an appointment with less than 72 hours' notice or fail to show up, I will be charged for the appointment due to losing the counselor’s time or other potential appointments.

3. I (We) understand that confidentiality is an integral part of the counseling process, and my counselor is careful to protect confidentiality, desiring to operate under high ethical principles. However, there are times when my counselor must share certain information with others, such as revealed information that indicates a genuine potential for harm to me or others. In that case, counselors may have to share that information with the appropriate authorities or family members, being obligated by conscience and the laws of the State of Florida regarding counseling relationships.

4. I (We) understand that Impact Family Inc. has cameras in the building to monitor movements for security purposes. All inbound or outbound contact with the client via phone or webcam sessions may be recorded for quality insurance and kept in a secure HIPPA-compliant data file/center(Google Drive) with two-factor authentication. If recorded, all data will be deleted or turned over to the client upon written request on our contact page.

5. I (We) understand that contributing online or by phone demonstrates that I have read, heard, and agreed with these essential terms. I will read further on the website (www.impact.vision/terms) any other terms and conditions not communicated in this summary agreement statement.

5. I (We) now agree to hold all independently contracted Christian Counselors affiliated with Impact Family Counseling Network and its leadership harmless from any advice, counsel, or suggestions rendered during our counseling sessions. I (We) recognize that their role is to assist me/us in hearing and understanding God’s will in the matters we discuss. Therefore, we will not prosecute or engage in any litigation negatively affecting Impact Family Inc., Impact Family Biblical Christian Counseling Network, Impact Family Network, or organizations granting them the ability and resources to provide counseling services. We will follow an Amicable Dispute Resolution with Professional Christian Mediation Companies only.

6. I (We) agree not to attempt to subpoena or require any counselor to appear in any legal proceeding related to any matters discussed during counseling, nor will I (we) attempt to subpoena any notes or records associated with this counseling.

C. CHRISTIAN COUNSELING CONTRIBUTIONS

Impact Family Inc. is a faith-based ministry that depends upon the generous contributions of its counselees, members, and partners. Impact Family Inc. underwrites additional costs. We encourage you to pray and ask the Lord what you should give above the suggested amount on the counselor’s profile.

If you cannot offer that amount financially or in kind, if your Church refuses to help with a contribution, or if you have questions, please discuss them with our team or apply for a scholarship.

Checks or money orders are to be written to Impact Family Inc. You can also donate online at www.impact.vision/donate. To schedule a session, please go directly to our team page.

Suggested Donation Amounts For Sessions:

$85-$150 new clients/intake session
$85-$150 existing clients
Sessions last, on average, 50-150 minutes.
See current contribution amounts here https://impact.vision/session

For mailed-in payments with written permission from the Executive director, please send your check or money order to us at:

Impact Family Inc.
8362 Pines Blvd. #116
Pembroke Pines, FL 33024

Counseling sessions with mailed payments are not scheduled until contributions have been received, deposited and cleared in bank account. Please schedule 2 to 3 weeks before sending the contribution.

D. CHRISTIAN COUNSELING CHILDCARE

Unfortunately, Impact Family Inc. is unable to provide childcare. If bringing a child, please ensure the issues you present to the counselor are appropriate for them.

E. CHRISTIAN COUNSELING CANCELLATION, RESCHEDULING, & REFUNDS

Clients are entitled to a full refund if they cancel 72 hours before the appointment by clicking the cancelation link on your client portal bookings page and clicking refund on the orders page. View Refund Process Tutorial
Clients are entitled to a full refund if the counselor does not attend the session after 15 minutes of their scheduled appointment. After 10 minutes of waiting, you must
- 1) knock on their door (Client's doing an office session)
- 2) call their phone number and extension that is listed in the email confirmation sent to your inbox
- 3) email them with the email address in the confirmation sent to your inbox
- 4) contact the support team through our contact page
If clients have verified documentation of a medical emergency or death in your immediate family, you are entitled to a 100% coupon to reschedule your session at another more convenient time.
To reschedule your session, go to your Client Portal @ Click Edit on your Session | Direct Link: https://impact.vision/calendar-client-portal
- Step 1: Login Into Your Client Portal & Cancel the Session | Direct Link: https://impact.vision/calendar-client-portal
- Step 2: Go To Orders And Request a Refund before the 72-hour deadline | Direct Link: https://impact.vision/my-account/orders
- Watch the refund tutorial for help.

View other terms and conditions.

Client Name*

Date*

Electronic Signature Agreement

By signing your name below, you are signing this consent form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Signature*

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Couples Survey Questions