Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

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Wedding Anniversary (Including Year) *

MM

DD

YYYY

Please Check Every Box Next to ALL Statements Below That Are True for Your Marriage History. *

This information will help us to accurately match you with a Mentor.

We married late in life (35 years or older)

We married young (under 20 years of age)

This is a second marriage

We have a large family (4 or more children)

We have a special-needs child

We have experienced the loss of a child

We have experienced infertility

We have dealt with the challenge of long work hours

We both work outside the home

We have learned how to stay connected despite a demanding travel schedule

We have experience with difficult in-laws

We are especially practiced at conflict resolution

We have had to learn healthy ways to communicate

We have navigated through an employment crisis

We have pulled through a serious illness

We have experienced unfaithfulness and forgiveness

We’ve gone through a financial crisis together

We have learned the benefit of having a financial budget

We have experienced recovery from an addiction

We have learned the importance of keeping our sex life happy

We especially enjoy doing challenging adventures together

We have found ways to enjoy the same types of activities together

One of us has found healing from a difficult family of origin issue

We have come from a different faith background

We were raised with different cultural backgrounds