Intake Questionnaire

About Workshop 3 Hours

The 3-Hour Workshop is a live virtual group session for couples, held over video with multiple couples joining together. Dr. Clint and Angelica lead the session directly, guiding real-time conversation and exercises rather than a recorded or one-way presentation.

This workshop runs on weekends only and is built around group interaction, giving you the chance to work through relationship patterns alongside other couples in a similar season of their relationship. Expect a mix of guided discussion, live coaching from Clint and Angelica, and exercises you can apply immediately.

This is a group format, not a private session, so it's a lower-cost way to get direct access to Clint and Angelica while learning from the dynamics of other couples in the room.

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Workshop 3 Hours

Thank you for your interest in A Friendly Shoulder Workshop 3 Hours. This questionnaire helps us understand your relationship, your goals, and any safety or health needs, so we can create the safest and most supportive experience possible. Please answer honestly and in as much detail as you feel comfortable. Both partners should review the questions together. For certain questions, each partner can respond separately.

Full name. Partner A

DOB mm/dd/yyyy. Partner A

Phone

Full name. Partner B

DOB mm/dd/yyyy. Partner B

Phone

Address

How did you hear about us? (friend, social media, therapist, etc.):

Are you married/engaged/dating/living together/separated but working on reconnection/other?

What made you decide to reach out and consider this retreat now, at this point in your relationship?

What are your top 3 goals for this retreat as a couple?

On a scale of 1 to 10, how committed are you to working on this relationship right now? Partner A

On a scale of 1–10, how committed are you to working on this relationship right now? Partner B

What are the main challenges or repeating conflicts in your relationship right now?

If you had to name one ‘core theme’ of your struggles (for example: trust, communication, emotional distance, conflict style, past betrayal, intimacy, parenting, money, etc.), what would it be?

How do conflicts usually look between you? (quiet distance, explosive arguments, shutting down, walking away, etc.)

Is there any history of: emotional abuse, physical aggression, threatening behavior, or feeling unsafe in this relationship? If yes, please describe what feels important for us to know.

Do you have any financial concerns about attending (payment plans, deposits, etc.) that you’d like us to know about so we can discuss options?

Is there anything else you would like us to know about you, your partner, or your relationship before we confirm your spot?

Thank you for taking the time to fill this out. Everything you share is treated with respect and confidentiality within the limits of safety and the law. Once we receive your questionnaire, we will review it and contact you with the next steps.

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