Your Demographic Information

Your Insurance Company name and your Policy ID Card #:
Note:  The Policy Number is different from the Group Number (which I don't need).
Yet another note:  I'll ask for scans of your ID card in a separate email.

And if the policy is in someone else's name, please include:
That person's full name (as it appears on the card or policy), as well as their middle initial:
That person's date of birth:
That person's address (only if it is different from yours):
That person's phone (only if it is different from yours):
Whether the plan was purchased through The Marketplace or through an Employer:
The Employer/Company providing the plan (if relevant):

Relationship HistoryHow long have you known each other?
Dated?
Lived together?
Married?
Kids and pets in the mix (names and ages)?

Do drugs (e.g., Alcohol) affect interactions in a negative/problematic way?

Any resentments preventing closeness, desire to connect, and ability to see the person in the present?

Any past traumas that lead to triggers, reactivity, and attempts to control the other person?