The purpose of this form is to aid your significant other’s counsellor in supporting you to share your concerns about your loved one in a way where everyone is afforded the support they may need to hear difficult feedback. We recognize this can be a challenging thing to do, yet we encourage you to be honest in your disclosure. We are here to support you each step of the way and will provide a safe space for you to be heard. To fill out, please place your cursor in the provided field and just start writing, then go to the next question and do the same until finished. Boxes will expand if needed. Thank you for your effort.