Neuro Code Marriage Coaching

Marriage Coaching Intake Form

For best results, each spouse completes this form separately and as honestly as possible. Please submit within 48 hours of scheduling your appointment.

Agreements

I understand that the personal information I share in this form will be used solely to prepare for and conduct coaching sessions, and will be kept confidential.I agree to answer every question as honestly as I can. I understand that the accuracy of my answers directly affects the quality of the coaching I receive.

Personal Information

First Name *

Last Name *

Cell / Text Number *

Email *

Spouse's First Name *

Spouse's Last Name *

Marriage Assessment

How would you rate your marriage overall? 0

0 — Want a Divorce10 — Happily Ever After

What is the main challenge in your marriage? *

How often does this challenge impact your marriage? 0

0 — Never10 — Daily

What change do you most desire in your marriage? *

What change do you most desire in your spouse? *

How often does your spouse's behavior negatively impact you? 0

0 — Never10 — Daily

Relationship Statements

For each statement below, select the option that most honestly reflects your current experience. There are no right or wrong answers.

My partner accepts me as I am

I am good enough for this relationship

I choose to be here

I feel wanted

My partner is loyal

I am loyal

My partner makes sound financial choices

I make sound financial choices

My partner prioritizes us

I prioritize us

I feel loved

I love my partner

I feel safe

I am emotionally overwhelmed

I am mentally overwhelmed

I avoid problems

My partner avoids problems

I avoid conflict

My partner avoids conflict

I am often critical

My partner is often critical

I feel like a failure

I feel neglected

I am completely honest

My partner is completely honest

I forgive easily

I show compassion

I respect my partner

My partner respects me

My partner improves my self-image

My partner inspires me to improve

My partner supports my interests and goals

I avoid hard things

I regulate my emotions effectively

My partner regulates emotions effectively

I feel competent

My partner is competent

I understand my partner's perspective

My partner understands my perspective

I communicate my needs confidently

I understand my partner's needs

Responsibilities are shared fairly

I feel authentic in this relationship

My needs exceed my partner's

I enjoy trying new things

Final Agreements

I take full personal responsibility for my own thoughts, feelings, and actions. I understand that real change requires my own commitment and effort.I understand that Trevor Dimick is not a licensed medical or mental health professional. Coaching is not a substitute for medical, psychiatric, or psychological treatment.I agree not to record, reproduce, or share any part of my coaching sessions, materials, or proprietary methods without express written consent.

Signature

Date *

Signature (type your full name) *