Copy of Assessment for Individual Coaching May Day Specials Question Title * 1. What is your name and age? Question Title * 2. Rank the issues that are most pressing in your marriage needs. 1 2 3 4 5 6 Financial Issues 1 2 3 4 5 6 Co-Parenting Issues 1 2 3 4 5 6 Intimacy/Sexual Issues 1 2 3 4 5 6 Trust Issues 1 2 3 4 5 6 Communication Issues 1 2 3 4 5 6 Other Question Title * 3. Answer this question. When my marriage is GREAT, we are being/doing....... Question Title * 4. Answer this question. When my marriage is AWFUL, we are being/doing...... Question Title * 5. Have you ever started the process or considered divorce? If yes, when and why did you not complete the process? Question Title * 6. If you could change 1 thing (in relation to your marriage).... About yourself About your spouse Question Title * 7. Have you received Counseling or Coaching? If yes, tell me about that experience. Question Title * 8. If you had a magic wand and could wave it and make your marriage PERFECT, what would your marriage look like? Question Title * 9. How important are the aspects of your marriage to you? Not important Somewhat important Very important Our marriage can not survive without it Sex & intimacy Sex & intimacy Not important Sex & intimacy Somewhat important Sex & intimacy Very important Sex & intimacy Our marriage can not survive without it Sex & intimacy Communication Communication Not important Communication Somewhat important Communication Very important Communication Our marriage can not survive without it Communication Having fun together Having fun together Not important Having fun together Somewhat important Having fun together Very important Having fun together Our marriage can not survive without it Having fun together Question Title * 10. Please give us some ways that we can contact you! Address City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number Done