Marriage Mentor Request - Husband
Name of Spouse*
Street Address*
Home Phone*
Cell Phone*
Ethnic Origin
Highest Level of Education*
What is your affiliation with Spring Creek Church?*
 I am not a regular attender
 I am a regular attender
 I am a member
If you do not attend Spring Creek, do you have another church home?
How would you describe the current state of your marriage?*
Pet Peeves*
Check the answer below that best describes you*
 Seeker/not yet a Christ follower
 New Christian
 Committed Christian
 Do not believe in Jesus
 I am not sure what I believe
How long have you been married to your current spouse?*
Why do you want marriage mentoring?
If you have children, please enter their name(s) and age(s)
Have you been previously married? (If no, skip to "Mentee Agreement" at bottom of page)*
If yes, how many times?
How long were you previously married?
When was the divorce final?
What was the reason for the divorce?
Did you try to reconcile?
Who filed for divorce?
Did your spouse commit adultery?
Did you commit adultery?
Were you a Christian at that time?
Was your spouse a Christian?
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.
(Click Box Below)*