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Consultation Request Form

Please answer all of the questions on this page. We know it's a bit long but it will really help us help you. The answers to these questions, especially the comments section, will tell us a lot about how we can most effectively help you. Once we receive your answers we will be in contact within two business hours to schedule a consultation. All information is held in the strictest confidence.

 
          Name:
          Phone:
         Cell Phone
         E-mail Address:
        Your Occupation
        Your Spouses Occupation

Your age:


Your spouses age:


Number of years with your spouse:
 
Dating Living Together Married

Number of Family Members Including Yourself:
 

Tell us to what extent the situations described below represent a current problem for you by checking the number corresponding to your opinion according to the following scale:

1: It is not at all a current problem
2: It is a slight problem
3: It is a moderate problem
4 It is a significant problem
5: It is a very significant problem

 
 Children are a source of problems or tensions between you and your spouse.

1 2 3 4 5

Stepchildren are a source of problems or tensions between you and your spouse.

1 2 3 4 5

In-laws are a source of problems or tensions between you and your spouse.

1 2 3 4 5

Your ex is a source of problems or tensions between you and your spouse.

1 2 3 4 5

Your spouse's ex is a source of problems or tensions between you and your spouse.

1 2 3 4 5

Dealing with the legal problems that arise from living in a blended family.

1 2 3 4 5

Dealing with the financial problems that arise from living in a blended family.

1 2 3 4 5

Finding resources or friends who understand the difficulties I am experiencing as a member of a blended family.

1 2 3 4 5

Organizing family events (birthdays, holidays, etc.) in the context of a blended family.

1 2 3 4 5

Sharing spaces in the house with different members of the family.

1 2 3 4 5

Participating in family events in the context of a blended family.

1 2 3 4 5

Reconciling my religious values with my life in a blended family.

1 2 3 4 5

Spending one-on-one time with my spouse.

1 2 3 4 5

Jealousy over the time my spouse spends with his/her kids.

1 2 3 4 5

Accepting the presence of a former spouse while in a relationship with my current spouse.

1 2 3 4 5

Being recognized as a couple by each of our original families.

1 2 3 4 5

Knowing how to react when my children express negative emotions about our blended family.

1 2 3 4 5

Reconciling the way my spouse and I feel about raising children.

1 2 3 4 5

Dealing with loving my children more than my stepchildren.

1 2 3 4 5

Dealing with the fact that my spouse criticizes the way I act with my children.

1 2 3 4 5

Feeling caught in the middle between my children and my spouse.

1 2 3 4 5

Dealing with the fact that my children and spouse argue.

1 2 3 4 5

Dealing with the fact that my children and stepchildren argue.

1 2 3 4 5

Accepting that my family is different from what I imagined.

1 2 3 4 5

Understanding my spouse's expectations with regard to my role as a stepparent.

1 2 3 4 5

Disciplining my spouse's children.

1 2 3 4 5

Feeling I have "my" place in the family.

1 2 3 4 5

Living with children whose values and lifestyle are different than mine.

1 2 3 4 5

Knowing how to react when my spouses children express positive feelings about me.

1 2 3 4 5

Knowing how to react when my spouses children express negative feelings about me.

1 2 3 4 5

 


Comments and Questions:

 

Suggest Possible Times for Your Consultation

Please give us some possible appointment times. We work on Monday through Friday from 8:00 AM to 8:00 pm (Pacific Time). We do not work on weekends.

We need two or more days lead time to book an appointment, so please don't request an appointment as soon as today or tomorrow.

In the box below, write in 3 possible appointment times that can work for you. Give us at least 3 possible days and as many hours in those days as you are available. Express the hours in terms of your local time zone.

Here's an example:

"Mon June 8 from 2 to 6 -- Wed June 10 from 3 to 8 -- Fri June 12 from 12 to 4"

Your Available Times: *required*


Your Time Zone:
 Eastern Central Mountain Pacific

Your Preference for a Coach?
 Either One Steve Straub Barbara Straub
We will contact you within 2 business hours to set an appointment

 

 

 

For more info call:
(800) 946-8112

Did you know?

There is a pattern of success for blended families.

Putting your marriage first is essential for blended family success.

The biological parent should do most of the disciplining at first.

It's OK to feel differently about your own children than you do about your stepchildren.

We can help you create the happy marriage and family situation that you really want.

 

FREE HELP FOR YOUR BLENDED FAMILY


 Get the information you need to create peace and harmony in your home, subscribe to Blending Families Today. This free email advice alone will help you eliminate some of the problems you may be having. And, in addition to sending you regular email counsel, we'll send you three free e-books that you can download and use to create peace and harmony in your home: "Establish Your House Rules", The Stepmothers 4 Week Plan for Less Stress", "Out With The Myths & In With the Truth" each worth $12.00 just for subscribing. No Catch.

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We will NEVER share or sell your information. Your privacy is very important to us.

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Phone: (800) 946-8112 | E-mail: help@winningstepfamilies.com