Welcome! You have selected Marriage and Family Therapy (MFT). How would you want us to assist you? *Marital ConflictPremarital CounselingParenting ChallengesFamily Communication IssuesDivorce and SeparationBlended Family DynamicsConflict ResolutionIntimacy and Sexual IssuesParent-Child Relationship IssuesSupporting Children and Teens with Emotional IssuesSubstance Abuse and Addiction in FamiliesChronic Illness and Disability in the FamilyGrief and Loss in the FamilyFinancial Stress in Marriage and Family LifeMental Health Support for Family MembersLife Transitions and Family AdjustmentCultural and Intergenerational DifferencesWork-Life Balance for Couples and FamiliesBefore we continue, let's have your name, email address and phone number.First Name *Please tell us your nameSurname Name *Please tell us your nameEmail Address *Enter valid email addressPhone Number *Enter valid phone number0 / 11Lovely! Please take this free assessment.Do you feel that your communication style positively impacts your relationship with each other? *YesNoDo you feel that you have established positive traditions or habits in your relationship that you’d like to continue or build upon? *YesNoAre you comfortable with how you both handle conflicts, and do you feel it leads to healthy resolutions? *YesNoDo you feel that responsibilities within the family are or might be fairly divided and supportive? *YesNoAre you comfortable expressing your needs and emotions to each other? *YesNoHave recent changes or external stressors that has significantly affected or you feel might affect your family dynamics? *YesNoHow old are you? *Select Age18192021222324252627282930313233343536383940414243444647484950515253545556575859606162636465666768697070+Please ensure you are 18+ to receive therapy from usGender *Please select your genderMaleFemaleFor your therapy session, which of these is your most preferred? *Physical-session-(Coming-to-our-office)Video sessionVoice only sessionText messaging sessionHow would you describe your financial status? *GoodAverageStrugglingHow did you hear about Mercy-B Therapy Cafe? *Search engineFacebookInstagramYouTubeDoctorTherapistTelevisionFriend/Family memberRadioNewspaperOther websiteNone of the aboveSubmitSave as DraftPlease do not fill in this field.
