Empower Love - Breakthrough Session Application

Name*

First NameLast Name
Best Email*
example@example.com
Where did you find Maya?*
What is your current relationship status?*

SingleIn a relationship that I should probably leaveMarried or in a serious relationship and I want to stay together
What is your main goal for working together?*

I want to get into a great relationshipI want to get married and/or have kidsI want to heal my attachment style and feel like my best selfI want to know if I should leave my current partner
What is going on in your love life that had you reach out for support?*
Choose the statement that best describes your situation

My love life is not that bad, but I'm curious how to make it better.I'm pretty frustrated with my love life and feel ready to do what it takes to find a great partner.I'm at the end of my rope and in a lot of pain. Help me now!
How has dating unavailable men negatively affected your life? Has it created problems in your career, friendships, ability to parent, etc.?
What kinds of things have you tried in the past to improve your love life? (Check all that apply)

BooksTherapyCoachingPrograms/WorkshopsDating SitesProfessional MatchmakingPsychics/Astrologers/TarotWardrobeCosmetic SurgeryPersonal Trainer/GymKeeping busy to distract yourselfOther
Why is it important for you to solve this problem right now so you are no longer dating unavailable men and can attract the right partner?
If someone told me to spend several hours a week, for several months taking specific actions that would help me heal my attachment style and call in the best relationship of my life, I would...*

Do it, because I'm ready and I have the time.Make the space because this is a priority for me.I don't have the time and I'm too busy right now.
Right now...*

I'm ready to transform my love life once and for all, and I have the financial resources to get started now.I want to heal and find my partner, and can get access to financial resources to get started now.I'm not open to investing financial resources because I don't have access to them, so I can't get started now.
What is your career/profession or, if you're not currently working, what do you love to do most?*
Our team will call you at the date & time selected. Our time and your time are valuable and we request that you commit to your appointment by typing this sentence in the box below – "I promise to show up and be in a quiet place, near my computer, for a full hour, during my breakthrough session."*
Promise
Contact Tags
If you experience any technical difficulty submitting this application please contact support@empowerlove.us.
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