Navigating Betrayal and Relationship Rupture Marriage Health Questionnaire & Consent Form

  • Navigating Betrayal and Relationship Rupture 6-Week Group

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  • Format: (000) 000-0000.

  • Can you tell us a little bit about your relationship?

  • Can you tell us about what's going on?

  • Can you tell us about your support network?

  • Can you tell us about you're hopes with getting help?

  • Marriage Health

    Coaching Agreement & Consent Form

  • Our Approach

    Marriage Health provides relationship coaching services from a faith-based perspective. We work with individuals and couples facing relationship challenges, including communication issues, infidelity, and betrayal trauma. Our approach combines faith principles with clinical knowledge and research-based practices.

    Coaching vs. Therapy

    Please understand that coaching is distinct from therapy or counseling. As coaches, we:

    • Focus on present challenges and future growth
    • Provide guidance, accountability, and support
    • Do not diagnose or treat mental health conditions
    • May suggest referrals to licensed therapists when appropriate

    Confidentiality & Its Limits

    We maintain strict confidentiality with the following four exceptions:

    1. If we believe you are at risk of harming yourself or others
    2. If we learn of abuse or neglect of a child, elderly, or vulnerable person
    3. If required by law or court order
    4. If you provide written permission to share information

    Faith Component

    Our coaching incorporates Christian principles while respecting diverse beliefs. Please let us know if you have preferences regarding how faith is addressed in your sessions.

    Financial Agreement

    • The $300 fee for the 6-week workshop are due upon registration. 

    Crisis Situations 

    Marriage Health is not equipped to provide emergency services.

    • For immediate mental health emergencies: Call 988 (National Crisis Hotline)
    • For safety emergencies: Call 911
    • For domestic violence support: Call 1-800-799-7233

    Communication

    • Sessions are conducted via secure video conferencing
    • Email and text communications are not guaranteed to be confidential
    • We aim to respond to all communications within 24 business hours

    Termination

    Either party may end the coaching relationship at any time. We recommend a final session to ensure proper closure and referrals if needed.

    Consent Agreement

    By signing below, I acknowledge that:

    • I have read and understand this agreement
    • I understand the nature and limits of coaching services
    • I consent to participate in coaching with Marriage Health
    • I understand that payment is due at the time of registration
    • I can ask questions about this agreement at any time
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      Your card will not be charged until after each session with Marriage Health.

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