REPAIR: Marriage Mentoring Request

Address

Phone number *

Spouse name (first and last): *

Spouse contact info: email, phone number *

Check this box to confirm that both members of the couple agree to being paired with a mentor couple.

Wedding Anniversary (including year) *

Children *

Yes, I have children

No, I do not have children

Do you believe in Jesus Christ as your Lord and Savior? (self) *

Yes

No

Do you believe in Jesus Christ as your Lord and Savior? (spouse) *

Yes

No

How long have you been attending LifePointe? *

Do you have any unusual scheduling issues that may impact when you can meet with your mentors?

Why are you interested in Marriage Mentoring?

Select ALL that apply:

To learn healthy conflict resolution skills

To improve communication

Navigating an employment crisis

Dealing with a serious illness

Recovering from unfaithfulness

Experiencing financial difficulty or crisis

Coping with addiction or recovery

Addressing physical intimacy challenges

Loss of emotional intimacy

Struggling to connect with each other

Managing difficulties with extended family

Parenting challenges with children living at home

Parenting challenges with adult children

Balancing work and family life

Aligning long-term goals or vision

Coping with trauma or loss

Other

Marriage History/Details

To help us match you with a mentor couple, select ALL the statements that are true of your marriage:

We married late in life (35 years or older)

We married young (under 20 years of age)

We are newly married (less than 2 years)

This is a second marriage

We have a large family (4 or more children)

We have a blended family (step-children involved)

We are recovering from a separation

We are navigating post-affair recovery

We have a special-needs child

We have experienced the loss of a child

We have experienced infertility

We are pursuing adoption or fostering children

We both work outside the home

One or both of us own or run a business

We are dealing with the challenge of long work hours

One of us is a stay-at-home parent

We are navigating a long-distance relationship or frequent separations due to work

One or both of us are in active military service or veterans

We have a demanding travel schedule

We have difficult in-laws

We want to do challenging adventures together

We want to pursue and enjoy the same types of activities together

We have a difficult family of origin issue

We have different faith backgrounds

We have differing levels of spiritual commitment or practice

We were raised with different cultural backgrounds

We are empty nesters

We are dealing with aging parents or caregiving responsibilities

Other

Please feel free to write any additional comments that would help us match you with a mentor couple:

Thank you for providing us with this information. We will review your responses and get back to you shortly.