Couple Forward Solutions Application

Name* This field is required.

First Name

Last Name

E-mail* This field is required.

Partner's Name

First Name

Last Name

Partner's Email

example@example.com

Phone Number to Call (If Zoom does not work or you opted for a phone call instead of zoom)* This field is required.

Your Facebook Profile * This field is required.

So we can make sure you have group access

How did you Hear about us?* This field is required.

Facebook Ad

Facebook Messanger

Facebook Group

Google

Friend

Other

Tell us briefly about your relationship status and challenges* This field is required.

As you think about the primary reason that brings you here, how would you rate your overall concern about it?* This field is required.

Normal, just want grow

Moderate

Serious

Very Serious

Please rate your current level of relationship happiness 1-10, 10 being the happiest.* This field is required.

What are your biggest strengths as a couple?* This field is required.

How satisfied are you with the frequency of your sexual relations?* This field is required.

Very Satisfied

Satisfied

Unsatisfied

Very Unsatisfied

How satisfied are you with the quality of your sexual relations?* This field is required.

Very Satisfied

Satisfied

Unsatisfied

Very Unsatisfied

Please make at least one suggestion as to something you could personally do to improve the relationship regardless of what your partner does:* This field is required.

be specific

Do you perceive that either you or your partner has withdrawn from the relationship?* This field is required.

Do either you or your partner drink alcohol to intoxication or take drugs to intoxication?* This field is required.

Has either of you threatened to separate or divorce as a result of the current relationship problems? * This field is required.

List your top three concerns that you have in your relationship with your partner (1 being the most problematic):* This field is required.

be specific

What would be the most important criteria for you if we are a good fit to work together?* This field is required.

What do you hope to accomplish if you join Couple Forward Solutions?* This field is required.

Are you willing to invest in our coaching for your relationship if you feel it is what you need? (Cash, Credit Cards, Loan, PayPal Credit, Payment options)* This field is required.

Yes, I know investment is important & required

No, I'm not willing to invest time & money

If accepted, how soon can you get started? * This field is required.

I realize and acknowledge I am booking a real time Clarity Call (30 min) with Christian or Amber and I promise to respect their time by showing up to the call on time.* This field is required.

YES

I have added the appointment to my calendar and will confirm any email or text that requires confirmation.* This field is required.

YES