A Positive Marriage Counseling Alternative

Fulfilled Couple Club Application
(Wife Edition)

First Name *

Last Name *

Primary Email address *

Your husband's name *

Years Married *

Family last name *

Look at the five pictures below. Which picture best describes your marriage right now? Click the picture below for a larger version. (Opens in new window.)*

Your age *

Your phone number *

Months/years known prior to wedding: *

Have either of you been married before? *

Number of children *

Names and ages of children * (Please note if biological children are from this marriage or previous marriages)

What is the single most influential issue that brought your marriage to the point of not being what you hoped for? *

Name 3 additional issues that have been making your marriage difficult in the past year. *

What would be the one thing your husband could do for you that would change how you feel about him? (Be specific i.e., always be patient and listen to my complete point when I’m talking, etc.) *

What is one thing you could do that would most likely change how your husband treats you? *

What would your marriage be like if you had your version of a “happy marriage”? (Write one sentence describing what it would be like if things could be the way you want them to be in your marriage) *

Name the top three changes your husband should make right away, so you feel that he really does love you. *

Name the top three things you are willing to do differently so your husband feels you really do love him. *

How motivated are you to do those three things on a 1 to 10 scale with 1 being low and 10 being high? (Write a brief explanation for your answer if you wish.)*

On a scale of 1 to 10 (1-low, 10-high), how willing are you to forgive your husband for his past ways of treating you? (Write a brief explanation for your answer if you wish.) *

How many months you are willing to wait while your husband does what he’s supposed to do to show his love for you and for you to do what you need to show your love for him? *

Read the definitions of a GOOD STUDENT, OK STUDENT and NON STUDENT. Describe why you believe you will be a GOOD STUDENT of what is taught in this program, rather than a NON-STUDENT or an OK STUDENT.

GOOD STUDENT: Listens closely to everything taught. Asks many questions based on experiences outside of class. Reads all the materials and takes notes. Tells the class leader about both successes and failures in efforts to apply what is being learned.

OK STUDENT: Attends to the subject only when in class. Occasionally tunes out material being covered. Participates in learning as long as class leader is asking questions. Forgets material outside class and does not apply it. Rarely asks questions during class.

NON-STUDENT: Cannot figure out a reason why the material should be absorbed and applied. Attends class for reasons unrelated to the subject. Delays or misses classes. Learns little. Applies nothing. *


	To learn more about Fulfilled Couple's Marriage 101 program , get complete details here.