Relationship Coaching Application

1

Before you begin, this program is designed for couples that live close or with each other. No long distance couples.

2

Your Full Name* This field is required.

First Name

Last Name

3

Your Preferred Pronouns* This field is required.

4

Your Email Address* This field is required.

example@example.com

5

Partner's Full Name* This field is required.

First Name

Last Name

6

Partner's Email Address* This field is required.

example@example.com

7

Partner's Preferred Pronouns* This field is required.

8

Social Media Handle (e.g., Instagram username)

9

Phone Number* This field is required.

Please enter a valid phone number.

10

How long have you been together?* This field is required.

0 to 2 years

2 years to 5 years

5 years to 10 years

11+ years

11

Have you tried other forms of individual or couples therapy?* This field is required.

Individual therapy

No

Couples therapy

Both

12

This program is designed for lesbian-identified partnerships. Are you both ready to improve and invest in your relationship as a couple?* This field is required.

Yes

No

13

Describe your primary concern that is coming up within your relationship that makes this the perfect time for coaching.* This field is required.

14

Where do you see yourself or your relationship 6 months from now if nothing changes?* This field is required.

15

Rebuilding desire requires stepping out of the 'safe roommate' dynamic and having vulnerable, sometimes unfamiliar conversations. Are you both ready to unlearn your old patterns and try a completely new approach to your intimacy?* This field is required.

16

Do you live within the U.S.?* This field is required.

Yes

No

18

How soon are you wanting support?* This field is required.

ASAP

Willing to wait but sooner than later

We're not in a rush