LIBERTY SCHOOL OF COUNSELLING

MARRIAGE COUNSELLING EVALUATION FORM

PERSONAL HISTORY

General Information:
Name: ____________________________ Date of Birth_________ Age_______
Address: ________________________________________________________
Phone: Home: ______________________

Business______________________

Mobile: _____________________

email____________________

Country of Origin: _________________

Nationality: __________________

Marital Status: Please tick

Single___ Married___Separated___ Widowed ___Divorced___ Co-Habiting ___
If married, name of spouse ______________ Date of Birth________ Age_____ Occupation:
______________
Education: last year completed ______________________________
Degree/Diploma________________________________
Major and Minor (if college) _______________________
How did you hear about LCC marriage Counseling Ministry: ____________________?
Is this your first Marriage? Yes/No___have you had sex with your fianc/fiance? Yes/no
If yes, how many times: ____are there any children from previous marriage(s) yes/no ___
If yes, how many: ___are you wiling to accept any child/children as part of your new family_____
Have you receive counseling from another church? Yes/no if yes, where: ________
When do you intend to wed? ________________ And Where: ____________
Have done traditional marriage/engagement? Yes/no if yes Where______________
Have you been married at the registry? Yes/no: _____ if yes where? ____________
What Date: ____________ Please Tick?
Please tick one of the days you will attend counselling: Tuesdays 07:00pm to09:00pm
3rd Saturdays of the months 10:00am to 13:00pm

Church Information
Religion____________________ church name ___________________________
Address___________________________ when did you join the church______________
Your pastors name: _______________ Do you pay tithe______ Tithe no_______
Do you belong to any fellowship: _________________ if yes which one: _____________
Are you a worker: _____ if yes which Dept/Ministry __________________
Minister/HODS Name: __________________ have you attended LCC new comers class
_______________ if yes when _____________Do you speak in tongues: __________
Do you belong to any home care group ___________ if yes which one___________
Health Status
What is your blood type? ___________ Do you take alcohol? Yes/no_____ do you smoke yes/no
__________
Describe your general health:
Very Good___ Good ___ Average_____ Poor________
Describe all important present or past illnesses or handicaps:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________
Have you had or do you have sexually Transmitted diseases (STD)? Yes/no if yes, please state:
__________________________________________________________
When was your last physical exam? ____________________ Result_____________
Who is your present physician? Name______________________________
Address________________________________
Are you presently on medication: Yes_________ No________?
If yes what kind and for what purpose?
_________________________________________________________________
Have you ever been under treatment for emotional problems?
Yes_____________ No______________ if yes, describe when where and under whose care
________________________________________________________
Personal Attributes
Describe yourself in terms of personal characteristics
a) Positive traits___________________________________________________

b) Negativetraits_____________________________________________________
Describe the worst thing that ever happened to you
________________________________________________________________________________
________________________________________________________________________________
______________________
Describe the best thing that ever happened to
you_____________________________________________________________________________
________________________________________________________________________________
__________________
Describe the person who had the greatest influence on your
life______________________________________________________________________________
________________________________________________________________________________
____________

FAMILY HISTORY
Father name: _____________________ living or Deceased? _________________
Occupation _____________________________ Age_________________
Education __________________________
Marital status Married_______________ separated________
Divorced_______________ widowed___________
Martial History: has your father ever been separated _________________
Divorced_______________ widowed___________
Mother name: _____________________ living or Deceased? _______________
Occupation _____________________________ Age_________________
Education __________________________
Marital status Married_______________ separated________
Divorced_______________ widowed___________
Martial History: has your mother ever been separated _________________
Divorced_______________ widowed___________

Description of Your Parents

Fathers character traits:
Positive:
________________________________________________________________________________
_______________________________
Negative
________________________________________________________________________________
_________________________________________
Mothers character traits:
Positive:
________________________________________________________________________________
_______________________________
Negative
________________________________________________________________________________
_________________________________________
In what ways would you like to be like your parents?
Different from your Father?
________________________________________________________________________________
________________________________________
Different from your Mother?
________________________________________________________________________________
________________________________________
Description of your parents Relationship
Describe what you observed in the following areas of your parents relationship:
Friendship/companionship
General Characteristics:
________________________________________________________________________________
_________________________________

Frequency of being together:

________________________________________________________________________________
______________________________________

Intensity of Relationship (competitive, combative, cool, casual, affectionate, Romantic,

etc):_____________________________________________________________________________
____________________________________________
Decision making/leadership Roles: (who led and in what
ways?)___________________________________________________________________________
__________________________________________________________________
Religious Training in the home (who trained and how)
________________________________________________________________________________
_______________________________________
Management of finances: (who managed money, what did they do with the money and how
successful were they in this
task?)____________________________________________________________________________
_________________________________________________________
What three qualities inn your parents marriage would you like to duplicate in your marriage?
1___________________________________________________________
2___________________________________________________________
3____________________________________________________________
What three aspects of your parents marriage would you not want to duplicate in your marriage?
1_______________________________________________________
2_______________________________________________________
3_______________________________________________________
How many brothers and sisters do you have? ________________________
Describe your relationships with your brothers and sisters during childhood
years___________________________________________________________
Describe any major marital crisis in your parents marriage
The conflict(s):____________________________________________________
The reason of the
conflict(s):________________________________________________________________________
____________________________________________
The resolution of the conflict(s):____________________________________________________

Describe your feelings during this time:

________________________________________________________________________________
_____________________________
Are your feelings different
now_____________________________________________________________________________
______________________________________
Were there any chemical dependency problems (either drugs or alcohol) in your family (parents,
brothers, sisters)?
Yes____________________ No________________________
If yes,how has that problem affected you?
________________________________________________________________________________
________________________________________________________________________________
___________________________________________________
DATING HISTORY

How did you meet?

________________________________________________________________________________
__________________________________________________
How long have you known each other? ________________________________________
How long have you dated? _________________________________________________
How long have you been engaged? ___________________________________________
Are you co-habiting with your fianc/fiance? __________________________________
How soon do you plan to be married? _____________________________________
Did you date others prior to meeting your fianc/fiance? Yes___________ No________
If yes, how many others have you dated? _____________________________
For how long? ________________________________
Have you been engaged before? ____________ if yes did the prior engagement result I marriage?
___________________________________ if it did not what ended the engagement?
_____________________________________
Do you love one another?________________________________
If yes what do you mean when you say you love someone? _________________________
Why do want to marry your fianc/fiance? (List five reasons in their order of importance to you.)
1__________________________________________________
2__________________________________________________
3__________________________________________________
4__________________________________________________
5__________________________________________________
What do you expect from marriage? Finish this statement:
I expect to get:

1_________________________________________
2_________________________________________
3__________________________________________
I expect to give:
1____________________________________________
2____________________________________________
3____________________________________________
In what ways do you think you will be a better person married than you could be by remaining
single?
________________________________________________________________________________
________________________________________________________________________________
_________________
Describe what you believe should be the husbands role in marriage. Be as specific as possible
.________________________________________________________________________________
________________________________________________________________________________
_______________________________________________________
Describe what you believe should be the wifes role in marriage. Be as specific as possible
.________________________________________________________________________________
________________________________________________________________________________
_______________________________________________________
Thank you for taking the time to complete this questionnaire.
PLEASE NOTE THAT WE WILL TREAT ANY INFORMATION YOU PROVIDE ON THIS
FORM IN STRICT CONFIDENCE.

DECLARATION
I---------------------------------------------------------------- declare that the information I have given is
true and I agree to supply further information if the Marriage Counseling Ministry (MCM) require
this. If information supplied is found to be incomplete or incorrect LCC may withdrew her
involvement in the marriage process.

SIGNATURE----------------------------------------------------NAME-------------------------------------------------------------DATE--------------------------------------------------------------

OFFICE USE
Date assessed----------------------------------------Name of Assessor------------------------------------Comments---------------------------------------------Signature-------------------------------------------------