Marriage Intake Form

1

Are you the husband or the wife?

I'm the HusbandI'm the Wife

2

Do you have kids together?

Yes, we have kidsNo, we don't have kids

3

Do you still live together with your spouse?

Yes, we live togetherNo, we don't live together

4

Have either of you filed for a divorce?

YesNo

5

How often do you feel wanted in your marriage?

I feel wanted all the time.

I feel wanted some of the time.

I rarely feel wanted.

I never feel wanted.

6

Please select all which apply to your current situation:

My spouse won't talk to me at all (ignoring my calls, blocked texts, etc).

There is/has been an affair in our marriage.

I don’t feel connected with my spouse.

My spouse has narcissistic tendencies.

We’ve faced addiction troubles (drugs, alcohol, pornography, gambling).

One or both of us have experienced mental health like depression, anxiety, PTSD.

Nothing above applies to my situation.

7

How important is it for you to get your spouse back?

It's extremely important for me.

It would be nice.

I'm impartial.

I don't want to get back with my spouse.

8

What do you miss the most about your marriage?

9

What have you tried so far to save your marriage?

Counseling/therapy.

Marriage coaching.

Online courses.

Self-help (marital books, Youtube videos)

Nothing mentioned above.

10

But that didn't work?

No, it didn't workIt didn't last...

11

Which best describes your situation?* This field is required.

I am willing to invest financially in saving my marriage.

I am NOT willing to invest financially in saving my marriage.

12

What is your name?* This field is required.Our marriage coaches regularly reach out to quiz submissions to find out more about the situation and how they can help.

First Name

Last Name

13

What is your contact email address?* This field is required.

example@example.com

14

And what is your phone number?* This field is required.Our marriage coaches may call/text you to find out more about your situation and how they can help.

Please enter a valid phone number.

15

You're almost there, let me quickly answer a question that I'm sure you're wondering:

"Who are you and how can you save my marriage?"

Hi, I'm Dr. John Grimani*

Saving marriages is my calling.

Let me share my goal with you:

My mission is to build Lion Heart Marriage Coaching into the number 1 marriage coaching company in the world...

(It's a big goal, but we're well on our way!)

In order to hit that goal, we simply have to be the best.

That's why rescuing couples from divorce and helping them get back on track is what team Lion Heart lives for.

We've done it hundreds of times (we've gotten pretty good at it).

There's nothing we haven't seen.

There's no client we haven't helped.

Affair? Alcohol? Addiction?

Partner already thrown in the towel?

Divorce already filed?

No problem.

We've saved much, much worse, trust me.

In fact, don't take my word for it, let me show you a few video testimonials from our happy clients...

(Maybe the first one will really resonate with you?)

Hit NEXT to see our testimonials, after that you can SUBMIT your quiz to get your RESULT.

*Founder of Lion Heart Marriage Coaching (DClinPsy and Ph.D. From Dartmouth and Yale)

16

Is Jimmy's situation like yours?

(Testimonial 1 of 3)

(Turn subtitles on)

Click NEXT to see another testimonial, or skip over it and SUBMIT.

17

Listen to Arianne's story, sound familiar?

(Testimonial 2 of 3)

(Turn subtitles on)

Click NEXT to see another testimonial, or skip over it and SUBMIT.

18

Does Reggie's situation resonate with you, too?

(Testimonial 3 of 3)

(Turn subtitles on)

Click SUBMIT to finish the quiz and get your RESULT...

19

Lead Source