Couples Consultation Application

Both partners must complete this application individually before the consultation is confirmed.

This consultation is designed for couples who are prepared to make one structured, adult attempt to understand the patterns shaping their relationship and determine whether meaningful repair is possible.

Please answer honestly and thoughtfully.

1. Basic Information

Full Name *

Email Address *

A valid email address is required.

Phone Number *

Age *

Suburb / Location *

Relationship Status *

Married De facto Partnered Separated but exploring repair Other

Please select a relationship status.

Length of Relationship *

Do you live together? *

Yes No

Please select an option.

Do you have children together? *

Yes No

Please select an option.

If yes, please note ages of children

2. Readiness

Are you both willing to attend the consultation together?

Yes No

On a scale of 1–10, how committed are you to making one deliberate attempt before deciding the future of this relationship?

Are you willing to examine your own contribution to the relationship dynamic — not only your partner's?

Yes No

Are you willing to hear difficult truths about the patterns affecting the relationship?

Yes No Unsure

Are you seeking clarity, repair, or both?

Clarity Repair Both Unsure

3. Current Relationship State

How would you describe the current state of the relationship?

Stable but repetitive conflict Increasing tension or distance Frequent unresolved conflict Emotionally disconnected On the brink of separation Currently separated but considering repair

How long have things felt this way?

What feels most difficult in the relationship right now?

What do you believe is at risk if nothing changes?

4. Current Relationship Pattern

Briefly describe the recurring conflict cycle you find yourselves in.

For example: one person pushes, the other withdraws; one shuts down, the other escalates; both become defensive; etc.

When conflict begins, what usually happens first?

Criticism or blame Defensiveness Withdrawal or silence Attempting to control or fix Avoiding the issue Emotional escalation Other (please describe)

When conflict escalates, what do you most commonly do?

Become critical or confrontational Shut down or go quiet Try to fix or manage everything Become defensive Avoid the conversation Leave the interaction Other (please describe)

What usually happens after the conflict?

We repair well We move on without resolving it We stay distant We revisit the same issue repeatedly It builds into further resentment

5. Emotional Triggers

What situations or themes tend to trigger arguments between you?

What topics are hardest to discuss calmly?

Select all that apply.

Money Parenting Intimacy Time / priorities Trust Communication Family / in-laws Household roles Work stress Other

When you feel triggered in the relationship, what do you most commonly feel underneath?

Select all that apply.

Rejected Unheard Controlled Criticised Abandoned Not good enough Unsafe Angry Ashamed Other (please describe)

6. Automatic Responses

In moments of conflict, do your reactions feel automatic rather than intentional?

Often Sometimes Rarely

Which statement best describes you under stress?

I become bigger, louder, or more forceful I shut down and go quiet I try to fix, please, or smooth things over I detach and stop engaging I become sharp, defensive, or reactive It depends on the situation

How easy is it for you to calm yourself once activated?

Very difficult Difficult Sometimes manageable Usually manageable

Do you feel you understand your own conflict pattern?

Yes Somewhat No

7. Relationship History

How long have these patterns been present in the relationship?

Have these patterns worsened over time?

Yes No Unsure

What have you already tried to improve the relationship?

Have you previously engaged in couples counselling, therapy, coaching, or relationship support?

No Yes

If yes, what was helpful?

What was not helpful?

What are you hoping will be different about this process?

8. Family of Origin / Early Learning

What did you learn about handling conflict in your family growing up?

How did your parents or caregivers typically handle disagreement?

Select all that apply.

Open discussion Avoidance Anger Silence Control Withdrawal Unpredictability I'm not sure

As a child, what did you tend to do to stay safe, accepted, or out of trouble?

Become compliant Become high-performing Become quiet Become helpful Become defensive Become invisible Fight back Other (please describe)

Do you feel those old coping patterns still appear in your adult relationship?

Yes Sometimes No Unsure

9. Responsibility & Accountability

Are you willing to take responsibility for your behaviour during conflict?

Yes No

Are you willing to examine the possibility that both of you contribute to the current pattern, even if in different ways?

Yes No

Do you believe your partner is the main problem in the relationship?

Yes No Partly / not entirely sure

Are you willing to work on behavioural change rather than only discussing feelings and past events?

Yes No Unsure

10. Commitment to the Work

If the relationship shows potential to improve, are you willing to commit to structured work over multiple sessions?

Yes No Unsure

Are you willing to practise behavioural changes between sessions?

Yes No

Are you willing to pause unhelpful patterns and practise new responses even when it feels uncomfortable?

Yes No Unsure

Do you want to save the relationship if meaningful change is possible?

Yes No Unsure

11. Separation / Rupture / Safety

Are either of you currently considering separation?

Yes No Unsure

Has either partner emotionally checked out of the relationship?

Yes No Unsure

Are there current legal issues affecting the relationship?

No Yes (please explain briefly)

Are there any safety concerns that may affect the suitability of this work?

No Yes (please explain briefly)

Please note: if there are serious safety, coercion, or violence concerns, this work may not be appropriate in its current form.

12. Scope & Suitability

I understand this is structured relational coaching and adult development work — not clinical therapy, psychological treatment, crisis counselling, or medical care.

Yes No

I understand that insight alone is not enough and that meaningful change requires responsibility and repetition.

Yes No

I understand that both partners are expected to engage respectfully in the consultation.

Yes No

13. Final Reflection

Why does this relationship deserve one final structured attempt? *

Take your time with this question. Your answer matters.

This field is required.

What would a stronger relationship make possible for you, your partner, and your family? *

This field is required.

Is there anything else important you believe I should know before deciding whether this work is suitable? *

This field is required.

All information provided in this application and during the consultation process is treated as private and confidential and managed with professional discretion.

I understand and acknowledge this. *

You must acknowledge this to continue.

✓ Thank you. Your application has been received. We'll be in touch shortly.

Couples Consultation Application

Book a Course