Personalized Dating Consult Application

1
How would you rate your dating life right now?* This field is required.
Poor
Average
Good
Excelent
2
What is your age?* This field is required.
3
What country are you from?* This field is required.
United States
Canada
UK
Australia
Europe
Other
4
What would you love to see happen after working with us when it comes to your results with women? What's your ideal outcome from working with us?* This field is required.
5
In your estimation, why haven't you achieved the kind of success with women you want so far in life?* This field is required.
6
On a scale of 1-10, what is your commitment to getting this part of your life settled once and for all?* This field is required.
We only want to take on guys that are committed that we know we can help for sure.
7
What would happen if you didn't get this part of your life fixed and you continued the way you have been? Is that future acceptable to you? Or is it hell on earth just imagining it?* This field is required.
8
What other programs have you tried? * This field is required.(i.e. speed dating, matchmaker, coaching programs)
9
Are you willing to invest in yourself to get this part of your life handled once and for all?* This field is required.
Yes
No
10
What do you do for a living?* This field is required.
11
Roughly what's your annual income?* This field is required.We want to make sure we don't prescribe anything that won't match your lifestyle and current situation.
$0 - $50,000
$50,000 - $100,000
$100,000 - $200,000
$200,000 Plus
12
What are some of your stressors in life right now?* This field is required.( choose all that apply )
My health or weight
I cant pay my bills / money is tight
My job is stressful
Im on disability
Not being able to get a good relationship
My family
Going Through A Divorce
13
We can't help everyone, why should we select you as a mentoring client and put our blood, sweat, and tears into helping you get the same success that we and past clients have achieved with women?* This field is required.
14
Are you coachable?* This field is required.
Yes
No
15
If you knew with 100% certainty that you would be able to achieve the results you wanted with women... how much would you be willing to invest over the next 6-12 months in achieving that outcome now?* This field is required.
$5000+ (I can afford to invest whatever is needed for me to get this taken care of, money is not a problem for me )
$3000 - $5000 (1 am comfortable financially and can invest this to get the service I want)
$1000 - $3000 (I'm willing to invest this amount, but can't afford to really invest more then this ) (totally okay )
Below $1000 (I don't have much funds to invest right now but I have a small amount I can invest)
16
Whats Your Name?* This field is required.
First Name
Last Name
17
What's the best cell phone number to reach you at if you are selected by Zues?* This field is required.
Please enter a valid phone number.
18
Email* This field is required.
example@example.com
19
Please verify that you are human* This field is required.
Should be Empty: