Living Love Sessions Form

Client Information Form

Please complete all sections and email to: lisa@relationallife.com or fax to Lisa Sullivan at 434-288-5893. Typing is preferable. Return to us at least 3 weekdays prior to your session. Keep answers brief! If you are single, disregard the couple's related questions.

YOUR INFORMATION

If your spouse/partner is also attending, they should complete their own copy independently and send confidentially.

Your Full Name

Your Age

Street Address

City

State

Zip Code

Home Phone

Business Phone

Mobile #

Email Address

Other / Additional Phone #(s)

Profession

Number of Years Married or in Relationship to Current Partner/Spouse

Children's Names and Ages

Previous Marriage(s) & Length of Marriage(s)

SPOUSE / PARTNER'S INFORMATION

Spouse/Partner's Name

Partner's Street Address

Partner's City

Partner's State

Partner's Zip

Partner's Age

Partner's Previous Marriage(s) & Number of Years Previously Married

Partner's Health

Partner's Profession

YOUR FAMILY OF ORIGIN

Mother's Name

Mother's Age

Mother's Location

Mother's Health

Mother's Profession

3 Adjectives to Describe Your Mother (1)

3 Adjectives to Describe Your Mother (2)

3 Adjectives to Describe Your Mother (3)

Father's Name

Father's Age

Father's Location

Father's Health

Father's Profession

3 Adjectives to Describe Your Father (1)

3 Adjectives to Describe Your Father (2)

3 Adjectives to Describe Your Father (3)

List of Therapists You Have Seen (start with current; include role and whether Terry has permission to contact them)

How Did You First Hear of Terry Real and His Work?

HEALTH CHECKLIST

Check all that apply and briefly explain where relevant.

Briefly Explain Any Checked Items Above

ADDITIONAL INFORMATION

Terry invites each of you attending the session to send a 200-word or less statement/summary about the issues and background of your story. Anything longer may not be read in full.

Your Personal Statement (200 words or less)

Today's Date