COMPLETE THE SURVEY BELOW

Morrow Marriage Presents: The White Picket Fence Project

The following questions will help us evaluate 5 of the most common marital issues with respect to your situation: communication, intimacy, family, finances and commitment. Please answer each section as honestly as possible.

Please note: this screening questionnaire will help us maximize your free session. We reserve the right to cancel any application that is deemed not to be a fit for Kathryn and her team. If you no show your appointment with no notice, you will not be given the opportunity rebook.

Communication

When you think about your normal pattern of communication with your husband, which of the following are present? Please select all that apply. *

Yelling

Name Calling

Eye Rolling

Negative Body Language

Lying

Accusing

Ignoring

Interrupting

Shutting Down

Stonewalling

Defensiveness

Criticism

Contempt

Verbal Threats

Belittling

Berating

Swearing

Misunderstanding

Language Barriers

No Communication

No problems - Communication is good

In your opinion, what is the biggest communication issue in your marriage? Please give 2-3 sentences. *

What strategies, if any, have you already tried to improve the communication patterns in your marriage? *

Intimacy

When considering the intimate side of your marriage, please select all that apply: *

Infidelity (physical)

Infidelity (emotional)

Infidelity (suspected but not confirmed)

Sexual Abuse/Assault

Low Libido/ Low Desire

Unmatched Sex Drives

Pregnancy/new baby/small children in the home

Nothing- Sex has never been our problem

Sex is (select all that apply): *

A job - we do it, but one of us doesn’t really want to

Rare or non existent

A source of conflict

None of the above - sex is not one of our problems

In 2-3 sentences, please outline the issues (if any) regarding intimacy in your marriage: *

Family

How long have you been together? *

2 years or less

3-5 years

6-10 years

More than 10 years

How many children do you have? *

1-3

4 or more

Do you have a blended family? *

Yes

What best describes the stage of life you are currently in? Select all that apply: *

No Children

Infant

Toddler/Preschooler

Elementary/Middle School

High School

Adult Children/Empty Nest

True or False

Disagreements regarding parenting styles/discipline/ punishments is causing a lot of conflict in the home:

Which statement best describes your “home” roles: *

Both partners play an equal part in parenting, pet care, household tasks and general household management. We are happy with our roles.

Division of work at home is unequal but we are content with our current roles. We have bigger problems to worry about.

Division of work at home is completely unfair and is causing conflict in the home.

Finances

Which statement best describes your “work” roles: *

Husband and wife both work full time

One partner works full time, one works part time

Both partners work part time

One partner works part time, one partner is not employed

Husband and wife are both unemployed

One or both partners is retired

Which statement best describes your “provider” roles: *

We have attained financial freedom. We each have financial authority and money is never a point of contention in our home.

We are financially blessed. We are very successful and share money almost effortlessly. Money comes and goes and is rarely a point of contention in our home. We live a good life and have everything we need.

We are comfortable. We have more than a little and less than a lot. We are financially responsible and have money in the bank/savings.

We live paycheck to paycheck. We pay our bills but that’s about it. Money is a source of stress because it is stretched so thin.

We do not make enough money to pay our monthly bills and are continuing to go more and more into debt. Money is one of our biggest sources of conflict because we simply do not have enough.

Commitment

At The White Picket Fence Project, we only work with women who are dead serious about having the life they deserve. We cannot commit to you if you cannot commit to building a better life.

From the list below, please select the reason(s) for your commitment to this marriage. *

I love my husband. I’m not happy, but I believe he’s worth it.

I’m attached to his family

I’m scared to be alone/single

I don’t want to lose my kids

I don’t trust my husband to raise my kids if we get divorced

I’m afraid of my husband

I value marriage

I made a commitment under God

Other religious reasons

On a scale from 1-10 with 10 being fully committed and 1 being ready for divorce, please rate your commitment level. *

Please explain your rating in 2-3 sentences *

How urgent is this call? *

I need help, like, YESTERDAY! Sign me up - I’m ready.

I need help ASAP, but I have a lot on my plate. I’m not sure if I can commit right now.

It’s not urgent; I’m just looking around to be proactive.

This session is free, but we have a program specifically designed for women who want to take control of the downward spiral and keep their families together. If you are a fit for the program, you might be invited to join our program

Which Of These Describes You Best? *

I would love to work with Kathryn and have the financial resources to do so

I need help with my marriage but money is an issue

Final Step: Contact Info

First Name *

Last Name *

Email *

Phone *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.