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.
First Name
Last Name
2
Best Email Address (Required)* This field is required.Please Double Check Your Email To Make Sure It Is Correct! - CY365 Team
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
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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
Spotify
Referral
Website
Relationship Assessment
Other
Other
7
What's your current relationship status* This field is required.Select all that apply.
Single
Dating
Engaged
Married
Divorced
Married But Separated
Widowed
It's Complicated
Other
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
Which of these best represents your current overall monthly income?* This field is required.
Less than $1,000/month
$1,000 to $3,000/month
$3,000 to$5,000/month
$5k-$10k/month
$10k-$15k+/month
10
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.
Huge
Large
Normal
Small
Ok
Ok
11
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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Small
Ok
Ok
12
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 a 30-min Coaching Session
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?* 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)
15
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)
Huge
Large
Normal
Small
Ok
Ok
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Investment* This field is required.We are looking for individuals who are truly ready to invest in their personal and relational growth. Christian relationship coaching requires commitment, emotional readiness, and teachability. Are you currently able to invest between $1,000 and $3,000 (USD) in your growth journey?
Yes, I have the funds
I have access to the funds
No, I don't have access to the funds
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Thank you for your interest in Completely You 365!

Again, our relationship coaching programs are currently paused indefinitely. You will now be redirected to our complimentary Christian Relationship Readiness Assessment to continue your journey toward a healthy, God centered relationship.
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