Restoration Diagnostic Client Forms

Complete these materials before your scheduled Diagnostic so your session can focus on understanding, prioritizing, and repair—not basic information gathering.

Privacy note: detailed client responses will be viewed inside the protected Marriage Medic WordPress system. Routine email notifications should only indicate that a form has been submitted and should not contain the sensitive answers themselves.

1. Client Intake & Safety Screen

Complete this form together. It captures the main concern, your desired win, relevant background, and the safety information needed to determine whether ordinary couple coaching is appropriate. Both spouses should review the answers and complete the signature section.

This field is for validation purposes and should be left unchanged.

A. Couple Information

Session date, if booked

B. Main Concern

C. Readiness & Ownership

On a 1–10 scale, how willing are you personally to change your own patterns or behavior?(Required)

D. Safety & Scope Screen

Check Yes or No. A “Yes” does not automatically disqualify you from support. It may change the safest or most appropriate next step.
Has there been physical violence, sexual violence, or a credible threat of violence in the relationship?(Required)
Is either spouse afraid of what may happen after disclosing concerns in a joint session?(Required)
Is there coercive control, stalking, intimidation, forced isolation, or control of money/communication that creates fear?(Required)
Are there current threats of self-harm, suicide, or harm to another person?(Required)
Are there current child-safety concerns?(Required)
Is there active substance use/addiction that is seriously impairing safety or functioning and may require specialized treatment?(Required)
Is there a restraining/protective order, active domestic-violence case, or major legal dispute that directly affects the marriage work?(Required)
Is either spouse in a severe mental-health crisis or unable to participate safely in ordinary coaching?(Required)
Is either spouse being pressured to attend or afraid to decline participation?(Required)
Do not use this form for an emergency. If someone is in immediate danger, use appropriate emergency or crisis resources rather than waiting for a coaching appointment.

E. Scope Acknowledgment

(Required)
(Required)
(Required)
(Required)

Signatures

Spouse 1 signature(Required)
Spouse 1 date(Required)
Spouse 2 signature(Required)
Spouse 2 date(Required)

2. Marriage Alignment Assessment

Each spouse should complete this assessment separately before the Restoration Diagnostic. It contains 20 statements across five pillars. Each statement is rated from 1–10, producing five pillar scores from 4–40 and a total score from 20–200.

The five pillars: Spiritual Alignment, Vision Alignment, Emotional Connection, Communication Health, and Intimacy & Partnership.

  • Rate each statement from 1 to 10. Add the 4 items in each pillar to get the pillar score out of 40. There is no score conversion step in this version.

  • Spiritual Alignment

  • Please enter a number from 1 to 10.
  • Please enter a number from 1 to 10.
  • Please enter a number from 1 to 10.
  • Please enter a number from 1 to 10.

  • Vision Alignment

  • Please enter a number from 1 to 10.
  • Please enter a number from 1 to 10.
  • Please enter a number from 1 to 10.
  • Please enter a number from 1 to 10.

  • Emotional Connection

  • Please enter a number from 1 to 10.
  • Please enter a number from 1 to 10.
  • Please enter a number from 1 to 10.
  • Please enter a number from 1 to 10.

  • Communication Health

  • Please enter a number from 1 to 10.
  • Please enter a number from 1 to 10.
  • Please enter a number from 1 to 10.
  • Please enter a number from 1 to 10.

  • Intimacy & Partnership

  • Please enter a number from 1 to 10.
  • Please enter a number from 1 to 10.
  • Please enter a number from 1 to 10.
  • Please enter a number from 1 to 10.
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Do not use this form for an emergency.

If someone is in immediate danger, use appropriate emergency or crisis resources rather than waiting for a coaching appointment.