First Name:

Last Name:

Street Address:

City:

State:

Zip:

Phone:

Age:

Email:

Occupation:

Relationship Status:

Highest Level of Education Obtained: High School (not graduated) High School Diploma Some College Associates Bachelors Masters Doctorate Other Education Obtained

When we call your home/work/cell may we say who we are calling?
Yes No

Emergency contact number:

Have you ever been in therapy before?
Yes No

If yes, please explain.

Are you taking any medication?
Yes No

If yes, please explain.

Do you have any mental or physical complications?
Yes No

Have you ever been hospitalized for mental or physical complications?
Yes No

Have you lost a relationship with someone you once loved because of anger, betrayal, or miscommunication?
Yes No

Do you miss the other person and wish he or she could still be in your life?
Yes No

What is this estrangement costing you? What price are you paying by having this rift in your life?

How is this estrangement benefiting you?

Why are you considering reconciliation at this time?

Have you made strides in healing the wound that led to the end of the relationship?
Yes No

Are you still fantasizing about revenge or retaliation?
Yes No

What are you still angry about? What do you resent about the other person or what he/she did?

Have you developed a sense of compassion for the other person?

Are you ready to take responsibility for your role in what happened?
Yes No

Could you apologize to the other person for your role in what happened?
Yes No

Why or why not?

Are you holding out for an apology or an acknowledgement that you were wronged?
Yes No

Could you say “no” in this relationship if you needed to?
Yes No

Are you being realistic about the other person or are you pinning your hopes on a fantasy?
Yes No

Would you consider a limited or partial reconciliation?
Yes No

Why or why not?

What risks do you face in attempting reconciliation at this time?

Given the risks inherent in reaching out, are you willing to face the worst possible scenario?
Yes No

If the other person rejects your attempts at reconciliation and your efforts fail, do you think you’d still feel good for having tried?
Yes No

Why or why not?

Do you have what it takes to rebuild this relationship?
Yes No

Briefly explain how you would like us to help you: