Marriage Takeover™ Intensive Application

Anniversary Date

Date

Wife Name*

First NameLast Name

Husband Name*

First NameLast Name

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address*

example@example.com

Email Address*

example@example.com

Best Number*

Area CodePhone Number

Are you a born again believer in Jesus Christ?*

Do you have any mental illnesses (documented or suspected)?*

YesNo

Have you ever been married before?*

YesNo

If previously married, are you?

WidowedDivorcedLegally Separated

If Divorced or Separated, when was your divorce or separation final?

Do you have children from your previous marriage or relationship?

YesNo

Do you have a criminal record?*

YesNo

Is Domestic violence currently present in your marriage?*

YesNo

What areas of your marriage are you seeking help with during our Marriage Intensive?*

Our Marriage Intensives require an investment of at least $5k (which does not include travel to the location)? Are you willing to invest in your legacy?*

YesNo

All Couples Must Comply to the Following:

All couples must complete all assigned reading and homework on time.
All couples must arrive on time as we have a very limited time together to tackle the most precious moments of your marriage.
All couples must attend the virtual intake process.

Final Acknowledgement

The purpose and goal of Marriage Takeover® marriage coaching is based on the word of God. We believe that having a relationship with God and Him being the source of your marriage is the KEY ingredient to its success.

We partner with only the best Therapist and Coaches to ensure you're served on a level that will save your marrige if you come engaged and willign to do the work required. Eric and Temeka of Marriage Takeover® and the entire existence of Marriage Takeover is help build up marriages and offer practical resources to help couples overcome daily life obstacles. It is our desire to help you build a strong foundation for your marriage through your relationship with God and each other.

We are licensed and ordained Pastors, certified Coaches and with our team provide the best blend to support your needs.

Marriage Takeover®, its employees, affiliates or subsidiaries will not be held liable for any damages should your marriage end as a result of any of our programs.

I acknowledge and understand that Eric & Temeka Thompson of Marriage Takeover® are licensed Pastors and not licensed therapists or counselors.*

I agree

I will not hold Eric & Temeka Thompson, Marriage Takeover®, its Staff, Therapists or mentors responsible or liable for anything whatsoever connected with the biblical instruction/counsel we are to receive.*

I agree

Signature*

Clear

Date Signed*

Date