Marriage Coaching Intake Form

Marriage Coaching Intake Form

Personal Information Usage Agreement *

I acknowledge that I have read, understood, and agree to the terms and conditions outlined in the Personal Information Usage Agreement below

All information collected by Rocky Mountain Brain Integration will be held confidential. Your information will not be shared, sold, or disclosed to anyone outside Rocky Mountain Brain Integration LLC without the client's written consent, or where mandated or permitted by law. Personal Identification Information like names, addresses, email addresses, and phone numbers will be used for identification and contact purposes only. Sensitive Data obtained from questioners, forms, and sessions will be used for services rendered only.

Honesty Agreement *

I acknowledge that I have read, understood, and agree to the terms and conditions outlined in the Honesty Agreement below

Honesty is the practice of aligning your words, actions, and representations with what you genuinely believe to be true — refusing to deceive, mislead, or misrepresent reality, even when the truth is inconvenient or costly to yourself. It is not merely the absence of lying. It includes accuracy, transparency, and the courage to speak what is real when silence or distortion would be easier. Honesty is the foundation of all other virtues. It establishes truth as the currency of all interaction. Without it, nothing else can be trusted. I agree to answer all questions honestly and to the best of my ability. Neuro Coding, Brain Integration, Neuro Life Coaching, and other services rendered by Rocky Mountain Brain Integration LLC hinges on your honesty with your coach and yourself. Any form of dishonesty hinders the process and limits results.

My Name *

First

Last

Cell/Text Number *

Email *

Spouse's Name *

First

Last

On a scale of 1 - 10; How would you rate the marriage? 0=want divorce; 10=happily ever after

Selected Value: 0

What is the main challenge in the marriage you would like to address?

On a scale of 1 - 10; How often does this challenge negatively impact the marriage? 0=never; 10=daily

Selected Value: 0

What is one thing you would like to change about the marriage?

What is one thing you would like to change about your spouse?

On a scale of 1 - 10; How often does the thing about your spouse, you want to change, negatively affect the marriage? 0=never; 10=daily

Selected Value: 0

My partner accepts me the way I am *

Please Select the Answer That Best Describes Your Relationship

I am good enough to be in the relationship *

Please Select the Answer That Best Describes Your Relationship

I choose to be in the relationship *

Please Select the Answer That Best Describes Your Relationship

I feel wanted in the relationship *

Please Select the Answer That Best Describes Your Relationship

I trust my partner to be loyal *

Please Select the Answer That Best Describes Your Relationship

I trust myself to be loyal *

Please Select the Answer That Best Describes Your Relationship

I trust my partner to make good financial choices *

Please Select the Answer That Best Describes Your Relationship

I trust myself to make good financial choices *

Please Select the Answer That Best Describes Your Relationship

I trust my partner to do what is best for us *

Please Select the Answer That Best Describes Your Relationship

I trust myself to do what is right for us *

Please Select the Answer That Best Describes Your Relationship

I feel loved by my partner *

Please Select the Answer That Best Describes Your Relationship

I feel love for my partner *

Please Select the Answer That Best Describes Your Relationship

I feel safe in the relationship *

Please Select the Answer That Best Describes Your Relationship

I feel emotional overwhelmed in the relationship *

Please Select the Answer That Best Describes Your Relationship

I feel mentally overwhelmed in the relationship *

Please Select the Answer That Best Describes Your Relationship

I avoid problems in the relationship *

Please Select the Answer That Best Describes Your Relationship

My partner avoids problems in the relationship *

Please Select the Answer That Best Describes Your Relationship

I avoid conflict in the relationship *

Please Select the Answer That Best Describes Your Relationship

My partner avoids conflict in the relationship *

Please Select the Answer That Best Describes Your Relationship

I am often critical of my partner *

Please Select the Answer That Best Describes Your Relationship

My partner is often critical of me *

Please Select the Answer That Best Describes Your Relationship

I feel like a failure in the relationship *

Please Select the Answer That Best Describes Your Relationship

I feel neglected by my partner *

Please Select the Answer That Best Describes Your Relationship

I am completely honest with my partner *

Please Select the Answer That Best Describes Your Relationship

My partner is completely honest with me *

Please Select the Answer That Best Describes Your Relationship

I easily forgive my partner *

Please Select the Answer That Best Describes Your Relationship

I show compassion toward my partner *

Please Select the Answer That Best Describes Your Relationship

I respect my partner *

Please Select the Answer That Best Describes Your Relationship

My partner respect me *

Please Select the Answer That Best Describes Your Relationship

My partner make me feel better about who I am *

Please Select the Answer That Best Describes Your Relationship

My partner inspire me to be a better person *

Please Select the Answer That Best Describes Your Relationship

My partner supports me in my interest and goals *

Please Select the Answer That Best Describes Your Relationship

I avoid doing hard things in the relationship *

Please Select the Answer That Best Describes Your Relationship

I am affective at regulating my emotions *

Please Select the Answer That Best Describes Your Relationship

My partner is affective at regulating his/her emotions *

Please Select the Answer That Best Describes Your Relationship

I feel competent in the relationship *

Please Select the Answer That Best Describes Your Relationship

I believe my partner is competent *

Please Select the Answer That Best Describes Your Relationship

I understand my partner's point of view *

Please Select the Answer That Best Describes Your Relationship

My partner understands my point of view *

Please Select the Answer That Best Describes Your Relationship

I feel confident communicating my needs to my partner *

Please Select the Answer That Best Describes Your Relationship

I feel confident I understand my partner's needs *

Please Select the Answer That Best Describes Your Relationship

I feel the relationship responsibilities are shared fairly *

Please Select the Answer That Best Describes Your Relationship

I feel authentic in the relationship *

Please Select the Answer That Best Describes Your Relationship

I feel my needs are more important than my partner's needs *

Please Select the Answer That Best Describes Your Relationship

I enjoy trying new things *

Please Select the Answer That Best Describes Your Relationship

Individual Responsibility Agreement *

I acknowledge that I have read, understood, and agree to the terms and conditions outlined in the Individual Responsibility Agreement below

I understand Marriage Coaching is a self-reflective process intended to support personal and relationship transformation. I accept full responsibility for my participation, choices, and results.

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Medical Wavier Agreement *

I acknowledge that I have read, understood, and agree to the terms and conditions outlined in the Medical Waiver Agreement below

Medical Waiver Agreement: Client and or Client’s Guardian here in after referred to as “Client” understand and agrees to the following: 1. I acknowledge that Rocky Mountain Brain Integration is not a medical provider and does not offer medical diagnoses, treatments, or prescriptions. 2. I understand that any information provided by Rocky Mountain Brain integration is not a substitute for professional medical advice, diagnosis, or treatment. 3. I affirm that I have consulted with my healthcare provider regarding my medical conditions, and I will continue to do so during my association with Rocky Mountain Brain Integration. 4. I understand that Rocky Mountain Brain Integration may collect and handle my protected health information (PHI) in accordance with Health Insurance Portability and Accountability Act (HIPAA) 5. I authorize the disclosure of my PHI to Rocky Mountain Brain Integration for the purpose of providing non-medical support. 6. I release Rocky Mountain Brain Integration, its employees, and affiliates from any liability for injury, loss, or damage that may result from my participation in Rocky Mountain Brain Integration’s services. 7. I understand the risk associated with any activities or recommendations provided by Rocky Mountain Brain Integration and voluntarily assume these risks.

Copyright and Intellectual Property Protection Agreement *

I acknowledge that I have read, understood, and agree to the terms and conditions outlined in the Copyright and Intellectual Property Protection Agreement below

By checking this box I agree the information I obtain from Rocky Mountain Brain Integration is for personal use only and agree to Not reproduce, copy, distribute, teach, sell and/or modify, change, or add to any part of the Neuro Code methodology without express written permission from the creator Trevor J. Dimick. This includes but is not limited to language structure, discovery frameworks, session processes, lists of Neuro Codes, code examples, and the full Neuro Code Editor

Date

Signature *

Please Type Your Name