Application Questionnaire

Application for a 30-Minute Relationship Strategy Call with Dr. Jackie
Name

First NameLast Name
Email
example@example.com
What is your partner’s name?
How long have you been in your committed relationship or married?
Is this your first marriage? First remarriage? Second remarriage? Other?
What are three things that are true about you as a partner? (For example, you believe you are very attentive to your partner’s needs; you don’t know what your partner wants anymore; everything you do is wrong lately).
What are the top three things you are most concerned about in your relationship right now?
What do you believe will happen if these concerns are not addressed?
What other solutions have you already invested in to try to address your concerns?
If you could wave a magic wand, what one thing would you change in yourself today?
If you could wave a magic wand, what one thing would you change in your partner today?
What might be possible for you and you partner if you finally resolve these concerns?
How ready are you to get help with your relationship concerns today?
What specific questions would you like to ask me during our conversation?
I only speak with SERIOUS couples. If our conversation is as successful as you and I hope it will be, what might stop you from making the financial investment in your relationship and enrolling in couple’s coaching at the end of our conversation?
Thank you for completing this application. I appreciate you taking the time to reflect on yourself, your partner and your relationship, and sharing with me so vulnerably.

I will be in touch shortly so we can schedule your Relationship Discovery Call.

Cheers to your joy with your partner!
Dr. Jackie
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Application for a 30-Minute Relationship Strategy Call with Dr. Jackie