Marriage Counseling Request

Submissions are treated with confidentiality, in shā' Allāh. Please share the details below so the masjid's team can reach out and arrange a suitable time to meet.

Contact

First NameLast NamePhone*Email*

Are you submitting this as

IndividualCouple

Best times to contact

Relationship

Relationship status

EngagedMarriedNikah onlyCivil marriageSeparated / considering separation

Length of relationship or marriage

Do you currently live together?

YesNo

Are children involved?

YesNo

Counseling context

Common areas of concern

CommunicationTrustIn-laws / extended familyFinancesParentingIntimacyReligion & practiceEmotional distanceAnger / conflictConsidering separation / divorce

In your own words, what prompted you to seek counseling now?

What are you hoping to gain from counseling?

Are both parties willing to participate honestly and respectfully?

YesUnsureNot applicable — individual

On a scale of 1–5, how committed do you feel to working through this?

12345

Have you sought counseling before?

NoYes, individualYes, couple

Safety

Are there any safety concerns we should be aware of?

YesNo

Counseling is not a substitute for emergency support. If someone is in immediate danger, call 911.

Are there any topics you are not comfortable discussing at this time?

Scheduling

In-person or virtual

In-personVirtualEither

Preferred days / times

Availability in the next 7–14 days

I understand that marriage counseling is a supportive and confidential process intended to provide guidance and help improve communication. I acknowledge that counseling is not legal advice or emergency support, and I agree to participate respectfully and honestly.

By submitting this form you consent to the masjid contacting you about this request. Your information is kept confidential and used only for this purpose.

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Upon the Salafi manhaj · since 1996