Marriage Coaching Intake Form

Marriage Coaching Intake Form

Personal Information Usage Agreement *

I Agree to the Following Personal Information Usage Agreement

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 Agree to the Following Honesty Agreement

I agree to answer all questions honestly and to the best of my ability. Brain Coding, Brain Integration, Life Coaching, and other services rendered by Rocky Mountain Brain Integration LLC hinges on your honesty with us 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

honest My trust

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 agree to the Individual Responsibility Agreement

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.

Medical Wavier Agreement *

I agree to the Medical Wavier Agreement Below

By checking this box, I acknowledge that Rocky Mountain Brain Integration is not a medical provider and does not offer medical diagnoses, treatment, or prescriptions. I understand that any information provided by Rocky Mountain Brain Integration is not a substitute for professional medical advice, diagnosis, or treatment. I understand the risks associated with any activities or recommendations provided by Rocky Mountain Brain Integration and voluntarily assume these risks. I release Rocky Mountain Brain Integration, its employees, and affiliates from any liability for injury, loss, or damage that may result from participation in Rocky Mountain Brain Integration's services.

Copyright and Intellectual Property Protection Agreement *

I agree to 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 Brain 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 brain codes, code examples, and the full Brain Code Editor

Date

Signature *

Please Type Your Name