Couple Questionnaire

Names (Husband and Wife) REQUIRED Please fill out this field. Please enter valid data.

What is your religious affiliation - Husband REQUIRED Please fill out this field. Please enter valid data.

What is your religious affiliation - Wife REQUIRED Please fill out this field. Please enter valid data.

If you are Catholic, were you married in the Catholic Church? REQUIRED Yes No Please fill out this field.

Do you attend Church regularly? REQUIRED Yes No Please fill out this field.

Do you include prayer, as a couple, in your daily life? REQUIRED Yes No Please fill out this field.

Do you read and discuss the Bible or Church teachings together? REQUIRED Yes No Somewhat Please fill out this field.

Do you currently use contraception? REQUIRED Yes No Please fill out this field.

Do you model healthy marriage behavior to your children? REQUIRED Yes No Somewhat Not Applicable Please fill out this field.

Do you have a healthy balance of work, leisure and a spiritual life? REQUIRED Yes No Somewhat Please fill out this field.

Do you take the time to go out on a date with each other monthly? REQUIRED Yes No Somewhat Please fill out this field.

Have you or your spouse ever been hospitalized for a mental illness, personality disorder, anxiety disorder, etc.? Please explain: REQUIRED Please fill out this field.

Have you or your spouse previously participated in any Therapy/Counseling? REQUIRED Yes No Please fill out this field.

If Yes, what kind?

How were you referred to the Covenant of Love Marriage Mentoring Ministry? REQUIRED Please fill out this field. Please enter valid data.

Do you have a preference of which mentor couple you would like to be paired with? REQUIRED Please fill out this field. Please enter valid data.

View Bios and Pictures of Mentor Couples:

Diocese of Davenport
Archdiocese of Dubuque

Do you have any questions or comments about the process? Please enter valid data.