Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Spouse's Name
*
First Name
Last Name
How did you hear about Jason and Ros?
*
Email
YouTube
TikTok
Facebook
Instagram
LinkedIn
Special Event
Friend/Colleague
Other
Are you a Veteran, First Responder, or currently serving as Active Duty Military Personnel?
*
Yes
No
Event Name
*
Friend/Colleague's Name
First Name
Last Name
City
*
State
*
Marriage Health Ratings
Rate each area of your marriage on a scale of 1 to 5.
1 = Very Unhealthy
5 = Very Healthy
How would you rate the quality of communication in your marriage?
*
Very Unhealthy
1
2
3
4
Very Healthy
5
1 is Very Unhealthy, 5 is Very Healthy
How would you rate the level of intimacy and intentional dating in your marriage?
*
Very Unhealthy
1
2
3
4
Very Healthy
5
1 is Very Unhealthy, 5 is Very Healthy
Rate how well you and your spouse share roles and responsibilities?
*
Very Unhealthy
1
2
3
4
Very Healthy
5
1 is Very Unhealthy, 5 is Very Healthy
Do you have children?
*
YES
NO
How well do you and your spouse navigate the impact of parenting on your marriage?
*
Very Unhealthy
1
2
3
4
Very Healthy
5
1 is Very Unhealthy, 5 is Very Healthy
How would you rate your alignment as a couple in your faith and spiritual life?
*
Very Unhealthy
1
2
3
4
Very Healthy
5
1 is Very Unhealthy, 5 is Very Healthy
Rate how well you and your spouse navigate your household finances
*
Very Unhealthy
1
2
3
4
Very Healthy
5
1 is Very Unhealthy, 5 is Very Healthy
What is your greatest concern or challenge within your marriage right now?
*
List the top 3 strengths in your marriage.
*
IMPORTANT: Select the Submit button below
AFTER
booking your consultation.
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