New Client Screening

New Client Screening Assessment

Welcome to the new client screening form. This form is designed to tell us more about you so we can assess how to best help you. If you are married it is best for you to answer these questions together. Please note we specialize in heterosexual couple issues. If you are using a mobile phone at various points you may need to put your phone in landscape mode to successfully navigate the form.

How did you find Lifestyle? *
If you used Google for your search, where did the link you clicked take you?
Select all that apply

Things you argue about

Please rate the things you argue about from least to greatest using the slider
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Undivided time is eye to eye contact without multitasking, phone, tv or other people to deal with.
Your insurance may cover the cost of therapy sessions. Even though we will verify your insurance it is best for you to contact them prior to your session. You are responsible for all services performed whether your insurance company pays or not.
Birth date of person on insurance card
Are you the policy holder/subscriber?
Birth date of person on insurance card
Check all that apply
All of our services are offered online only. Is that OK with you?
Check all that apply
Upload a photo of him
Maximum upload size: 5MB
Upload a photo of her
Maximum upload size: 5MB
Upload a photo of the two of you
Maximum upload size: 5MB
Upload a photo of yourself or the patient
Maximum upload size: 5MB
Upload a photo of the front of your insurance card
Maximum upload size: 5MB
Upload a photo of the back of your insurance card
Maximum upload size: 5MB

Your Relationship Trouble Severity Score was [6524]. This indicates that your relationship challenges are modest and that you would benefit most from Brief Intervention. Click submit to complete this screen and begin the process of scheduling your session with me.

Your Relationship Trouble Severity Score was [6524]. This indicates that your marriage is in would benefit most from my intense9-month Sizzling Hot Marriage Rehab Program.. I have been blessed to see tremendous progress in couples who commit to this program. My approach to transforming marriage takes couples on an intensive journey to work through the issues of the past and forge a bright and satisfying present with each other. This approach combines individual and couple coaching with a holistic systems approach to change that includes other couples who are going through similar experiences.

This intervention is Transformative! It will not only transform your marriage but each of you will feel better about yourself. This program is for couples who are experiencing challenges like affairs, sex addiction or other extensive issues that are tearing them apart. It appears that is where you guys are right now. I've found that just a few sessions with the therapist is not usually enough to reverse well established negative patterns couples have been repeating a long time in their marriage. Addictions may be difficult to break but they are not impossible. This 9-month coaching program gives couples the time they need to settle in on focusing seriously on making their marriage something they both can be proud of. Thus giving them ample opportunity to grow and sustain peace and harmony in their marriage for now and forever.

The program includes relationship testing, unlimited individual and couple coaching, two marriage retreats, weekly live video conference group classes (Sundays at 7 PM EST), partnering with other couples and 16 weekly online lessons. The program is executed in four phases. The first phase is the most intense phase that includes weekly individual and couple coaching, weekly online lessons and weekly group classes. You must commit to set aside a minimum of 5 hours each week to focus on each other, attend therapy, and complete the online lessons. One of the most exciting things about my program is that you don't have to ever come into an office to do it. From the comforts of your home, while you're on break from work, where ever you are in the world, you can enjoy the benefits of this program.

Schedule an appointment where I will continue my assessment and explain the program in detail to get you started.