Initial Enquiry and Suitability Form

Thank you for your interest in The Couples Reset Programme.

Couples Reset is a focused online programme for couples whose relationship feels in serious difficulty, but where both partners are still willing to explore whether repair may be possible.

Each partner should complete this form separately and privately. This helps me consider both perspectives and decide whether the programme may be safe, appropriate, and likely to be helpful at this time.

Completing this form does not mean the programme has been booked or that it will be offered. Once both forms have been received, I will review the information and contact you with the outcome.

This form is part of the enquiry process only. It is not counselling, diagnosis, emergency support, or crisis support.

Your answers are confidential to the provider. They will not be shared with your partner, and your partner will not be told what you have written.

The only exceptions are where disclosure is required by law, or where I reasonably believe disclosure to an appropriate service or authority is necessary to protect you or another person from serious harm.

If information provided by either partner suggests that the programme is not suitable at this time, I may decide not to offer the programme and explain that, based on the suitability screening, the programme is not appropriate at this time.

If you require urgent support, or there is an immediate risk of harm, please contact 999, NHS 111, your GP, Samaritans on 116 123, or your local emergency or crisis service.

Please answer as openly and accurately as you can.

Basic details

Full name *

Email address *

Mobile number *

Partner's full name *

Before you begin

Please tick the statements that apply to you.

I am completing this form myself.

I am at least 18 years old.

I understand that this form is a pre-booking safety and suitability screen for online couples work. It is not therapy, a diagnosis, or emergency or crisis support.

I understand that, if offered a place on the programme, both partners would need to attend online sessions together from the same private location, where we can speak freely and without interruptions.

I confirm that I have had the opportunity to read the Terms and Conditions.

Safety and suitability questions

The following questions are used only to help me consider whether the programme may be suitable to offer at this time. Some questions may not apply to your situation, but please answer them as openly and accurately as you can.

1. Are you willing to engage in exploring whether relationship repair may still be possible? *

Yes No

2. Are you freely choosing to take part in this programme? *

Yes No

3. Do you feel afraid of your partner, pressured, threatened, intimidated, controlled, or unable to speak freely in the relationship? *

Yes No

4. Are you currently able to give time and attention to working on your relationship outside the live sessions? *

Yes No

5. Are you currently involved in a romantic, sexual, or emotionally intimate relationship with another person outside your relationship with your partner? *

Yes No

6. Are you currently experiencing difficulties related to alcohol or substance use that may affect your ability to take part safely and consistently in the programme? *

Yes No

7. Are you currently experiencing thoughts of suicide? *

Yes No

8. Are you currently experiencing any immediate crisis or risk that could prevent you from safely participating in the programme? *

Yes No

9. Is there anything else that may affect your ability to participate safely in this online programme? *

Yes No

Declaration

I confirm that the information I have provided is accurate to the best of my knowledge.

I understand that this form is used to consider whether this programme may be appropriate to offer.

I understand that completing this form does not mean the programme has been booked and does not guarantee that the programme will be offered.