Dare to Be Different: Marriage Mentoring | Wife Form Name * First Name Last Name Spouse Name * First Name Last Name Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Ethnic Origin Highest Level of Education * High School Associate's Degree Bachelor's Degree Graduate + Why do you want to be mentored? * What is your attendance status at Bridge City Church? * I am a member I attend regularly I attend sometimes I have never attended If you don't attend Bridge City, do you attend somewhere else? Write the church name below Select the answer below that best describes you * Seeker/Not yet a Christ Follower New Christian Committed follow of Jesus Agnostic I'm not sure what I believe How long have you been married to your current spouse? * Have you been previously married? If yes, list how many times. * Type Yes or No in the blank. If you answered no to the question above, skip to the next section. How long have your previous marriage(s) lasted? When was the divorce final? What was the reason for the divorce? Did you try to reconcile? Yes No Who filed for divorce? I did My spouse did Did your spouse commit adultery? Yes No Did you commit adultery? Yes No Were you a Christian at the time? Yes No Was your spouse a Christian? Yes No Children Do you have any children? If yes, list their names and ages below. Please notate if the children are both yours and your current spouse or if they were from a previous marriage/relationship. Mentee Agreement * I understand that the Mentor Couple we meet with are not professional counselors, but volunteer marriage mentors who agree to share their life experiences with us in an effort to help us strengthen our marriage. I understand that we are responsible for the state of our marriage throughout the mentoring sessions or any time thereafter. I will allow Love and Respect/Dare to be Different and the church leaders to access our personal information. All data collected by Love and Respect/Dare to be Different will only be used as a quality control measure and will not be shared at any time with other parties. I agree Thank you!