Research Follow-up Questionnaire: One Year Survey

Please complete the following survey related to your marriage since leaving your Intensive. This survey will take approximately 10 to 15 minutes to complete on average. If both spouses receive this, we ask that each of you complete it separately. Do your best to answer every question. If you find one that is difficult to answer, please mark the item that most closely expresses how you feel. Thank you for your time and investment in helping us to continue to deliver quality service to you and others like you.

Question Title

* 1. Please list your Name and Date of Intensive *This information is for internal purposes only and will not be shared

Name (first initial and last name)

Date of Intensive (month and year)

Question Title

* 2. What type of Intensive did you attend?

2-day with 1 Therapist

2-day with 2 Therapists

3-day with 1 Therapist

3-day with 2 Therapists

4-day Group Intensive

6-day

Question Title

* 3. The person taking this survey is...

Male

Female

Question Title

* 4. What is your current marital status?

Married: in same home, same room

Married: Same home, separate rooms

Separated, not pursuing divorce

Separated, pursuing divorce

Divorced