Application For Relationship Coaching

1
What Is Your Current Relationship Or Dating Goal?* This field is required.
Getting Back Together With My Ex After A Breakup
Strengthening A Challenged Relationship
Emotionally Healing After A Breakup Or Divorce
Dating and Finding "The One"
2
Would you tell us more about what you've already done to try to reach your relationship goal... and the results you've had with these efforts?* This field is required.
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3
Was there any abuse involved in your situation (physical, mental, emotional)? Or was there anything illegal or unethical involved (for example, you or your partner were underage)? If none, simply type "none." If there was any, please give more details.* This field is required.
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4
Would you please share any other relevant information about your relationship situation that you think we should know?
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5
In your opinion what would make you a great coaching client? Why would we love working with you?* This field is required.
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6
How much are willing to invest in relationship coaching?* This field is required.
$6,000 - $10,000 USD
$3,000 - $5,000 USD
$1,000 - $2,000 USD
Less than $1,000 USD
Money is tight for me, but I might be able to afford coaching by using credit or taking out a loan, if I knew the coaching program was right for me.
7
Are you a United States citizen? We have partnered with a lending company to provide affordable financing for our clients... however, they are only able to offer their services to US citizens
YESNO
8
If we both felt good about working together, are there any practical reasons that might prevent us from doing that?For example, being in the process of taking out a mortgage and not being able to make any large transactions, or going through a complex divorce and having your financial records examined
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By the way... what's your name?* This field is required.
First Name
Last Name
10
What is the best email address to contact you at?* This field is required.
example@example.com
11
I Understand That I Am Applying For A Group Coaching Program That Involves A Blend Of Group And 1-on-1 Interactions... I Understand That I Am NOT Applying For Only 1-on-1 Coaching* This field is required.
I Understand
12
I understand that there are no refunds or cancellations with our coaching services, since it involves our time, resources, and energy. I also understand that coaching is not a substitute for the services of a therapist, psychologist, counselor, or any other metal health or legal professional* This field is required.
I Understand
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