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If you’re considering working with me, let’s talk! Let me know how I can help you.
Full Name
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First Name
Last Name
Phone
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Country Code
Phone Number
In which city are you located?
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Example: Hong Kong
E-mail
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Example@example.com
How did you hear about me?
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Briefly describe the difficult relationship that you're currently dealing with:
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What are your hopes/expectations/desires for this relationship?
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I am ready and willing to gain insight and find help with my Relationship.
Strongly Agree
Agree
Somewhat Agree
Somewhat Disagree
Disagree
Strongly Disagree
I’m ready to invest emotionally (and financially) to experience greater results in my Relationship and my life.
Strongly Agree
Agree
Somewhat Agree
Somewhat Disagree
Disagree
Strongly Disagree
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