Welcome to Relationships ReBuilt
You've taken the first step toward meaningful change. Let's get started by learning a little more about you and your goals.
What to Expect
This onboarding form helps Jim understand where you are right now and where you'd like to be. Your answers are completely confidential and will be used to tailor your experience with Relationships ReBuilt.
1
Share Your Story
Tell us about your current situation and what brought you here.
2
Set Your Goals
Define what success looks like for you and your relationships.
3
Get Your Plan
Jim will review your responses and create a personalized roadmap.
Why Clients Trust Relationships ReBuilt
"Jim helped me see patterns I'd been blind to for years. The onboarding process alone gave me clarity I hadn't felt in a long time."
— Former Client
"From the very first interaction, I felt heard and understood. The structured approach made me feel safe to open up about what really mattered."
— Former Client
Frequently Asked Questions
Have questions before getting started? Here are some common ones.
How long does the onboarding form take?
Most clients complete the form in about 30 minutes. Take your time — there are no wrong answers, and the more detail you share, the better Jim can tailor your experience.
Is my information kept confidential?
Absolutely. Everything you share is strictly confidential and will only be used by Jim to understand your situation and create your personalized plan.
What happens after I submit the form?
Jim will review your responses and reach out within 1–2 business days to schedule your first session and discuss your personalized roadmap.
Can I update my answers later?
Of course! Your journey is ongoing, and you can always share new information or update your goals as things evolve. Just reach out to Jim directly.
Relationships Rebuilt Coaching
Client Intake Form
Instructions
This form does not have to be completed in one sitting. Most clients take 60–90 minutes total. Use voice dictation for longer answers if helpful. Be as direct and detailed as possible. For factual items such as names and dates, enter them clearly. Formatting is not important. All responses are confidential.
Section 0 — Snapshot Summary
Section 1 — Current Status and Risk
Current living situation
Has divorce or separation been explicitly mentioned
Is there any legal involvement
Current communication level
Section 2 — Relationship History and Patterns
How long have you been together?
Are you married?
Do you have children together?
What have been the main recurring issues in the relationship?
Have there been previous breakups, separations, or major trust breaches?
Section 3 — Communication and Conflict
How do disagreements usually get handled?
When conflict happens, what do you most often feel?
Are there any topics that tend to trigger bigger arguments?
What would you like to improve about communication in the relationship?
Section 4 — Emotional Connection and Intimacy
How connected do you currently feel to your partner?
Which areas feel strained right now?
What helps you feel loved, valued, and secure in the relationship?
Section 5 — Goals for Counseling
What are you hoping to get out of counseling?
What would a healthier relationship look like to you?
Is there anything else you would like your counselor to know before the first session?
Section 5 — Trust, Honesty, and Safety
Has trust been broken in the relationship?
Checkboxes (optional answer)
☐ No major trust breach
☐ Yes, emotional betrayal
☐ Yes, physical infidelity
☐ Yes, dishonesty / secrecy
☐ Yes, financial betrayal
☐ Other
If trust has been broken, briefly explain what happened.
Paragraph (optional answer)
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Do you believe your partner is currently being honest with you?
Checkboxes (optional answer)
☐ Yes
☐ Mostly
☐ Unsure
☐ No
Do you feel emotionally safe in this relationship?
Checkboxes (optional answer)
☐ Yes
☐ Mostly
☐ Sometimes
☐ No
Is there any history of intimidation, threats, coercion, or abuse?
Checkboxes (optional answer)
☐ No
☐ Yes, emotional
☐ Yes, verbal
☐ Yes, physical
☐ Prefer to discuss privately
Section 6 — Your Role, Accountability, and Self-Awareness
What do you believe has been your contribution to the current problems?
Paragraph (optional answer)
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What patterns in yourself are you most wanting to change?
Paragraph (optional answer)
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How open are you to feedback, correction, and uncomfortable truth?
Checkboxes (optional answer)
☐ Very open
☐ Moderately open
☐ Somewhat resistant
☐ Very resistant right now
How willing are you to make behavioral changes even if your partner does not change immediately?
Checkboxes (optional answer)
☐ Very willing
☐ Somewhat willing
☐ Unsure
☐ Not willing
Section 7 — Partner Dynamics and Perspective
How do you think your partner would describe the relationship right now?
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How do you think your partner would describe you in conflict?
Paragraph (optional answer)
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Does your partner appear open to repair or reconciliation?
Checkboxes (optional answer)
☐ Yes, clearly
☐ Somewhat / inconsistently
☐ Unsure
☐ No, not at this time
What do you believe your partner needs most from you right now?
Paragraph (optional answer)
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Section 8 — Children, Family, and Household Environment
If children are involved, how are they being affected by the current situation?
Paragraph (optional answer)
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How aligned are you and your partner on parenting?
Checkboxes (optional answer)
☐ Very aligned
☐ Mostly aligned
☐ Often disagree
☐ Major source of conflict
☐ Not applicable
Are extended family members influencing the relationship?
Checkboxes (optional answer)
☐ No
☐ A little
☐ Yes, significantly
☐ Unsure
Describe the current household atmosphere.
Paragraph (optional answer)
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Section 9 — Intimacy, Affection, and Connection
How connected do you currently feel to your partner?
Checkboxes (optional answer)
☐ Very connected
☐ Somewhat connected
☐ Mostly disconnected
☐ Completely disconnected
How would you describe the current level of affection between you?
Checkboxes (optional answer)
☐ Strong and consistent
☐ Present but reduced
☐ Minimal
☐ Absent
Are there issues around physical intimacy or sexual connection that feel important to mention?
Paragraph (optional answer)
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What helps you feel loved, valued, or connected?
Paragraph (optional answer)
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Section 10 — Stressors, Mental Health, and Outside Pressures
What external stressors are currently affecting the relationship?
Checkboxes (optional answer)
☐ Work / career stress
☐ Financial pressure
☐ Parenting demands
☐ Health concerns
☐ Extended family issues
☐ Relocation / housing instability
☐ Other
Are there any mental health concerns impacting the relationship?
Checkboxes (optional answer)
☐ No significant concerns
☐ Anxiety
☐ Depression
☐ Trauma history
☐ Anger regulation issues
☐ Substance use concerns
☐ Prefer to discuss privately
How are you personally functioning day to day right now?
Checkboxes (optional answer)
☐ Stable and functioning well
☐ Stressed but managing
☐ Struggling significantly
☐ In crisis / overwhelmed
Anything else about your mental or emotional state that would be helpful to know?
Paragraph (optional answer)
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Section 11 — Previous Help and What Has Been Tried
Have you previously done counseling, coaching, or therapy related to this relationship?
Checkboxes (optional answer)
☐ No
☐ Yes, individual therapy
☐ Yes, couples therapy
☐ Yes, coaching
☐ Yes, multiple forms of support
What have you already tried to improve the relationship?
Paragraph (optional answer)
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What helped, even a little?
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What did not help or made things worse?
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Section 12 — Goals, Desired Outcome, and Vision
What outcome are you hoping for through this process?
Checkboxes (optional answer)
☐ Rebuild and strengthen the relationship
☐ Gain clarity about whether repair is possible
☐ Improve communication and co-parenting
☐ Stabilize an urgent situation
☐ Personal growth regardless of outcome
If things improved significantly, what would be different 90 days from now?
Paragraph (optional answer)
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What are your top 3 goals for coaching?
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What would success look like to you, specifically?
Paragraph (optional answer)
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Section 13 — Commitment, Capacity, and Readiness
How committed are you to doing the work required for change?
Checkboxes (optional answer)
☐ Fully committed
☐ Mostly committed
☐ Unsure
☐ Low commitment right now
How much time and energy can you realistically dedicate over the next 8–12 weeks?
Checkboxes (optional answer)
☐ High capacity
☐ Moderate capacity
☐ Limited capacity
☐ Very limited capacity
What obstacles could get in the way of your progress?
Paragraph (optional answer)
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What would help you stay consistent and engaged in the process?
Paragraph (optional answer)
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Section 14 — Final Notes and Anything Important Not Yet Asked
What feels most important for Jim to understand about your situation?
Paragraph (optional answer)
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Is there anything sensitive or private you would prefer to discuss live rather than write here?
Checkboxes (optional answer)
☐ No
☐ Yes
☐ Maybe
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Anything else you want to add?
Paragraph (optional answer)
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Would you like Jim to follow up with you about anything specific from this form?
Checkboxes (optional answer)
☐ Yes
☐ No
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