Please Click on REVIEW to move to Step 2 Click TAB2 first
 


Check which of the following describes issues you experience in your relationship:
(Note: all communications with Two Rivers Mediation are completely confidential)

Issue Type of Problem Duration of Problem At its worst, this
negatively impacts:
Fighting

Too Often
Severe

1 month 6 months
Longer
Work          Kids
Happiness Health
Sex

Not Often Enough
Not Satisfying

1 month 6 months
Longer
Work          Kids
Happiness Health
Money

Not Enough
Argue About

1 month 6 months
Longer
Work          Kids
Happiness Health
Feeling Judged

Sometimes
Often

1 month 6 months
Longer
Work          Kids
Happiness Health
Trust/Respect

Loss Due to Event
Generally Missing

1 month 6 months
Longer
Work          Kids
Happiness Health
Abuse

Emotional
Physical

1 month 6 months
Longer
Work          Kids
Happiness Health