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This Questionnaire should be filled out completely and returned before your first Premarital Counseling Session begins. After the forms are reviewed, an appointment will be made to meet with Dr. Cecil Poe. At this time, we will schedule an appointment to begin the pre-marriage counseling BIBLICALLY BASED program which will include the following content:

This program is approximately 9-12 hours (not including breaks)

  • COMMUNICATION
  • CONFLICT RESOLUTION
  • PARTNER STYLE AND HABITS
  • FINANCIAL MANAGEMENT
  • LEISURE ACTIVITIES
  • SEXUALITY AND AFFECTION
  • FAMILY AND FRIENDS RELATIONSHIP
  • ROLES CHILDREN AND PARENTING
  • SPIRITUAL BELIEFS
  • PRE-MARRIAGE AWARENESS QUESTIONNAIRE

**** Both you and your fiancé should complete the Premarital Form and Questionnaire separately, but both must be present for the actual Pre-Marriage counseling sessions with Dr. Cecil Poe.

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Name
Name of parent/guardian (if under 18 years)
Gender
Marital Status
May we leave a message?
May we leave a message?
May we email you?
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
Are you currently taking any prescription medication?
Have you ever been prescribed psychiatric medication?
GENERAL HEALTH AND MENTAL HEALTH INFORMATION
1. How would you rate your current physical health?
2. How would you rate your current sleeping habits?
5. Are you currently experiencing overwhelming sadness, grief or depression?
6. Are you currently experiencing anxiety, panic attacks or have any phobias?
7. Are you currently experiencing any chronic pain?
8. Do you drink alcohol more than once a week?
9. How often do you engage recreational drug use?
10. Are you currently in a romantic relationship?
FAMILY MENTAL HEALTH HISTORY
Alcohol/Substance Abuse
Anxiety
Depression
Domestic Violence
Eating Disorders
Obesity
Obsessive Compulsive Behavior
Schizophrenia
Suicide Attempts
ADDITIONAL INFORMATION
1. Are you currently employed?
2. Do you consider yourself to be spiritual or religious?
I agree to the above limits of confidentiality and understand their meanings and ramifications.
I agree to the above limits of confidentiality and understand their meanings and ramifications. (copy)

Get In Touch!

Contact Details

You can reach out to us with our number and email.

Phone:

404-436-4597 404-772-5858

Email Address:

capcivic@att.net

Address:

New Black Wall Street Market 8109 Mall Parkway, Suite 112, Madam CJ WalkerStonecrest"," Georgia 30038

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