Strong Men Strong Marriages Application Form
Thank you for your interest! You are already showing that you are a MAN OF ACTION by completing this application. Congratulations! Please complete all required fields and follow the recommended next steps. All answers are 100% CONFIDENTIAL and WILL NOT be shared. I'm looking forward to helping you become a stronger, more attractive man who creates a strong, passionate, intimate marriage!
Basic Information
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
How Did You Hear About Me?
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Strong Men Strong Marriages Podcast
Book - Strong Men Strong Marriages
YouTube Channel
Facebook/Instagram Ad
Referral
Other
What do you do for work?
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Do you aspire to live Christian values?
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Yes
No
I don't consider myself Christian but agree with the values of honesty and integrity
Are you self-motivated and goal-oriented? Give me an example from your life (work, sports, community, church etc).
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Has your wife agreed to do coaching/counseling with you?
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Yes
No
Are You...
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Married
Separated
In the divorce process
Are you living in the same house?
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Yes
No
Are you sleeping in the same bed?
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Yes
No
How long have you been married?
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How many times have you been married?
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How many times has your wife been married?
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What is your wife's name?
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Any children? If so, ages.
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Has there been emotional infidelity?
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Yes, by me
Yes, by my wife
Yes, by both
No
Has there been sexual infidelity?
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Yes, by me
Yes, by my wife
Yes, by both
No
Is pornography part of the problem in your marriage?
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Yes, currently
Yes, in the past
Yes, but my wife doesn't know about it
No
Other
About Your Marriage
What is the worst part and the biggest challenge about your marriage right now?
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5 years from now, if you don't fix this problem, what will your marriage look like? How will that affect your kids? Your health? Your relationships? Your work?
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What is your biggest fear of what will happen if you don't fix your marriage?
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Financial Questions
The next few questions will help you calculate the financial cost of a divorce. Not fun, but a useful exercise. I know this information is private, so not all questions are required. If you're not close to divorce currently, simply answer the required questions.
What Is Your Approximate Annual Income From All Sources?
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$0 to $49,000
$50,000 to $99,000
$100,000 to $249,000
$250,000+
Approximate Child Support ((Annual Income x 0.2) x (18 - your youngest child's age)
What Is The Approximate Current Value Of Your Savings And Investments NOT Including Home Equity (e.g. Rental Real Estate, Stocks, Bonds, Cryptocurrency, Savings And Checking Balances, etc.)
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$0 to $49,000
$50,000 to $99,000
$100,000 to $249,000
$250,000+
What is your approximate home equity?
Approximate Total Cost Of Divorce (Child support + $10,000 legal fees + cost of separating houses) + 1/2 of all investments, savings and home equity). As a shortcut, take your net worth and divide by two.
Where You Want Your Marriage To Be
If you could wave a magic wand what would your ideal marriage look like? Describe a typical day in your ideal marriage.
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If you're able to have that kind of marriage, what will that mean for your family 5 years from now? 10 years from now? For future generations?
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Your Commitment Level
On a scale of 1-10, how badly do you want that kind of marriage and family legacy?
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How committed are you to creating that kind of marriage and family legacy?
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I'll do whatever it takes
I'll try
I'll try if my wife tries
Time And Money
Becoming a strong, attractive man who creates a strong, passionate marriage and builds a legacy for generations to follow will require an investment of time and money.
Are you ready, willing and able to commit 15-20 minutes in the morning, 20-30 minutes during the day, and 15-20 minutes in the evening to transform yourself into a stronger, more attractive man?
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Yes
No
Are you ready, willing and able to make a significant financial investment to get the expert training, coaching and accountability to help you be a stronger man who creates a stronger, more passionate marriage? (This can be a business expense if you have a business)
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Yes
No
Your Responsibility
Who Can You Change?
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Myself
My Wife
When I try to change other people, what is that called?
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Manipulative
Impossible
All of the above
I do have some requirements for the men and couples I work with. Please anwer the following questions.
Are drugs or alcohol part of the problem? If so, how?
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Is there physical abuse involved? If so, how?
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Do you commit to being emotionally and sexually faithful to your wife while we work together?
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Yes
No
Send Dr. Mike My Application
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