Intake Questionnaire

About Weekend Reset Retreat

The Weekend Reset Retreat is a focused, in-person weekend built for couples ready to step away from daily life and work directly with us. Sessions run Saturday from 12:00 PM to 6:00 PM, and Sunday from 9:00 AM to 12:00 PM, with Dr. Clint and Angelica guiding you through the specific patterns and challenges affecting your relationship right now.

Sessions run in small groups of 1-6 couples, giving you both the depth of individual attention and the support of others going through similar work alongside you. Expect a mix of group sessions and private couple time, all designed to help you communicate more clearly, understand what's really driving conflict, and reconnect with each other.

We provide coffee and snacks throughout the day on Saturday to keep you fueled between sessions. Hotel accommodations and transportation are not included, so you're welcome to choose lodging that fits your budget and travel preferences.

This is a hands-on, intensive weekend, not a passive retreat. You'll leave with real clarity and real tools, not just a relaxing getaway.

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Weekend Reset Retreat

Thank you for your interest in A Friendly Shoulder Weekend Reset Retreat. This questionnaire helps us understand your relationship and your goals. 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 to 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.

Have either of you ever been diagnosed with a mental health condition (for example: depression, anxiety, bipolar, PTSD, etc.)? If yes, please describe only what you’re comfortable sharing and whether you are currently receiving support.

Are either of you currently taking any psychiatric medication? If yes, please list the medication names (if you feel comfortable) and whether everything is currently stable.

In the last year, has either partner experienced intense emotional distress, self-harm thoughts, or thoughts of not wanting to live? If yes, please share as much as you are comfortable with, so we can consider safety and support needs.

Is there any current or past struggle with addiction (alcohol, drugs, gambling, etc.) that you feel is important for us to know about?

How comfortable are you with group sharing (listening to other couples and sometimes sharing your own experience)?

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?

Emergency contact phone number

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

Please share with us a photo of two of you (For internal use only. It will never be shared with anyone or anywhere.)

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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