Rebuilding Your Relationship

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.(The phone number will be used to assign you to a Telegram group. You will not be receiving any calls. Please use the same phone number that you have used to register on Telegram. If you’re not sure, please open the app and double check. This is very important – otherwise, I will be able to add you to the group)
Please enter a valid phone number.
4
When you and your partner are arguing or in a rough patch, which of the following best describes how you feel about them?* This field is required.
“It’s like I’m dealing with a stranger – they aren’t the person I fell in love with.”
“I can’t stand them. I can’t even imagine why I ever fell in love with them in the first place.”
"I might not like them very much in that moment, but I know that my heart still holds a lot of love for them.”
“I love them very much – if I didn’t, I wouldn’t even care this much about the argument.”
5
What do you love about your partner? It can be anything, big or small, from physical features to a memory you hold dear.* This field is required.
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6
When your partner is around, which of the following best describes how you feel?* This field is required.
Empty and lonely
Content and comfortable
Excited, almost breathless
Frustrated and annoyed
Anxious and on-edge
Other
7
Complete this statement: “Our friends and family…* This field is required.
are mostly happy for us and rooting for us as a couple.”
hate seeing us fight or have problems, but generally keep their opinions to themselves.”
think we’re bad for each other and are constantly telling us to end things once and for all.”
used to give us advice, but have sort of gotten tired of our back and forth by now.”
have taken sides between the two of us.”
Other
8
If you met a good fairy, who offered to grant you one wish pertaining to your relationship, what would that wish be?* This field is required.
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9
Is there anything else you feel is important for the therapist to know before we start the chat?* This field is required.
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