A Friendly Shoulder Couples Retreat Intake Questionnaire

Thank you for your interest in A Friendly Shoulder Couples Retreat. 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.

Is there any current legal situation, restraining order, or active court case involving either partner that we should be aware of?

Have either of you ever worked with a therapist, coach, or counselor (individually or as a couple) before? If yes, what helped and what did not help?

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.

Are there any topics that feel especially sensitive or potentially triggering for you (for example: past trauma, violence, infidelity, addiction, grief, family issues)?

Do either of you have any significant physical health conditions we should know about (for example: heart issues, diabetes, epilepsy, recent surgeries, mobility limitations, etc.)?

Do either of you have any food allergies or intolerances? Please specify (for example: nuts, gluten, dairy, shellfish, soy, etc.).

Do either of you have any non-food allergies (for example: medications, bee stings, pets, pollen, etc.)?

28. What best describes your usual way of eating? (You can select more than one or add your own description.) – Omnivore (eat everything) – Vegetarian – Vegan / plant-based – Pescatarian – Low-carb / keto – Carnivore – Gluten-free

Are there any foods you absolutely do not eat (for ethical, religious, or personal reasons)?

Is there anything important about your energy levels, digestion, or physical stamina that we should keep in mind when planning activities (walks, gentle hikes, long sitting sessions, etc.)?

In our retreat we support cruelty free, healthy choices menu. Are you open to vegan diet for the time of retreat?

Do either of you currently use alcohol, recreational substances, or prescription medications in a way that you feel may affect your mood, sleep, or participation in the retreat? If yes, please describe briefly.

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

Are you comfortable with a retreat environment that is alcohol-free and focused on emotional and physical health?

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

Are you okay with gentle, structured exercises where you and your partner may be invited to speak honestly to each other in front of the group (never forced, always with consent)?

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 name and relationship to you (someone who is NOT attending the retreat with you):

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

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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@2025 by A Friendly Shoulder

A Friendly Shoulder Couples Retreat Intake Questionnaire

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