Dating & Relationship Mentorship Application

1
Full Name (Required)* This field is required.This form is to provide us with information about you and your situation so we can best serve you during your 30-min relationship coaching session with us.
First Name
Last Name
2
Best Email Address (Required)* This field is required.
jane.doe@yahoo.com
3
Country of Residence* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
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Afghanistan
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The Bahamas
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Mexico
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Mongolia
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Morocco
Mozambique
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Namibia
Nauru
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Netherlands
Netherlands Antilles
New Caledonia
New Zealand
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Northern Mariana
Norway
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Philippines
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Poland
Portugal
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Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
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Samoa
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Senegal
Serbia
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eSwatini
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Other
Country
4
Age* This field is required.
18-24
25-34
35-44
45-54
55+
5
Gender* This field is required.
Male
Female
6
How did you learn about us?* This field is required.
YouTube
LinkedIn
Instagram
Facebook
TikTok
Email Campaign
Other
7
What's your current relationship status* This field is required.Select all that apply.
Single
Dating
Engaged
Married
Divorced
Widowed
It's Complicated
8
What's your current student and/or work status* This field is required.Select all that apply.
Undergraduate Student
Graduate Student
Full-Time Employed
Part-Time Employed
Self-Employed
Unemployed
9
What is your biggest hurdle or obstacle in your single or dating life? * This field is required.Please be descriptive. Tell us about the challenges you're facing and what you've already tried.
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10
What is your primary goal for working with a dating & relationship coach? * This field is required.Be specific. What would "success" look like to you?
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What are you interested in?* This field is required.Select all that apply.
One-on-One Coaching (Program)
Group Coaching (Program)
Self-paced Course with 1 Coaching Session Follow-up
I Just Want to Seek Advice for My Situation on this 30-min Coaching Session
12
On a scale of 1–10, how ready are you to commit to a coaching program right now — considering your finances, time, and mental capacity?* This field is required.(1: Being Not Committed - 10: Being All In)
13
On a scale of 1–10, how ready are you to commit to a coaching program right now — considering your finances, time, and mental capacity? And explain why you chose that number.* This field is required.(1: Being Not Committed - 10: Being All In)
14
On a scale of 1–10, how ready are you to commit to a coaching program right now — considering your finances, time, and mental capacity? And explain why you chose that number.* This field is required.(1: Being Not Committed - 10: Being All In)
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30 Minute Coaching Session * This field is required.*All payments of $50 for the 30 Minute Coaching Session are non-refundable.
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ORDER SUMMARY
Total costUSD
30 Minute Coaching Session(Press the blue + plus button). This is focused, breakthrough session designed to help you gain clarity on your situation, understand what God is revealing, and identify your next steps in love, healing, or preparation for marriage. We’ll help you uncover the root of your concerns, receive biblical insight, and walk away with practical direction you can apply immediately. Perfect for singles, dating couples, or those seeking wise, godly guidance before making major relationship decisions.
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16
Thank you for your responses and payment!

Rescheduling & Cancellation Policy:
    •    Non-Refundable Fee: The $50 initial booking fee is non-refundable.
    •    Rescheduling Window: Changes made 24+ hours in advance are free of charge.
    •    One-Time Limit: Appointments may only be rescheduled one time. Subsequent changes will require a new booking and fee.
    •    Late Changes/No-Shows: Cancellations or rescheduling requests made within 24 hours of the appointment, as well as missed sessions, incur a $25 fee to re-book.
    •    Late Arrival: Arriving more than 15 minutes late will result in a cancelled session and a required rescheduling fee.

By clicking "Submit," I acknowledge that I have read and agree to the Rescheduling & Cancellation Policy stated above.

*You will be automatically redirected to our Calendly page to book your 30-Minute Zoom Coaching Session/Discovery Call with us.
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