Apply and Request Consultation (Couple)

1

How did you first find me?* This field is required.

Google

Facebook

Referral

Website

Psycholoty Today

GAYLESTA

Other

2

Which of the following best describes your current relationship status?* This field is required.Please tell me a little bit about yourself, so that I can better understand your situation

Single

Dating / Long Term Relationship / Engaged

Married

3

The relationship challenges you face at age 18 aren't the same as those you'll face at 68. To help me understand what you would most benefit from, which of the following best describes your age?* This field is required.

20's

30's

40's

50's

60's

70's and older

4

Can you tell me about yourself, and what's making you look for guidance at this time?* This field is required.Please be as detailed and specific as possible

5

Thank you! What are you looking to achieve as we work together?* This field is required.Again, please be as detailed and specific as possible. What’s your vision or dream here? What would you define “success” as?

6

Working with me usually requires an investment of at least $3,000. Have you made the funds available to make this investment right now?* This field is required.

Yes

No

7

Not Finished Yet... Last (And Most Important) Step! Please Confirm Your Contact Information Below, And Then Tell Me The Best Times To Contact You* This field is required.I will contact you within 48 hours after you submit this form.

Please enter your name

Please enter your email

Please enter your phone number

Please tell the best times of day to contact you