Queer Relationship Coaching Application

1
Your Name* This field is required.
First Name
Last Name
2
Your PronounsE.g. She/Her, He/Him, They/Them...etc.
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Please enter a valid phone number.
5
Your Instagram or TikTok Handle
6
Your Partner's Name* This field is required.
First Name
Last Name
7
Your Partner's PronounsE.g. She/Her, He/Him, They/Them...etc.
8
How Long Have You Been Together?* This field is required.
Under a year
1 - 5 years
6-10 years
11+ years
9
This Program is Designed for Lesbian-Identified Partnerships. Are You Both Ready to Improve & Invest in Your Relationship as a Couple?* This field is required.
YESNO
10
Have You Tried Other Forms of Individual or Couple Therapy/Coaching?* This field is required.Select all that apply
Couple Therapy/Coaching
Individual Therapy/Coaching
We haven't tried anything yet
11
What's the Primary Concern Coming Up Within Your Relationship That Makes This the Perfect Time for Coaching?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
12
Where Do You See Yourself or Your Relationship 6 Months From Now if Nothing Changes?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
13
Are You Willing to Get Out of Your Comfort Zone & Do Whatever it Takes to Create a Secure & Lasting Relationship?* This field is required.
YESNO
14
Do You Live Within the U.S.?* This field is required.
YESNO
15
We're so Glad You're Here! How Did You Find Us?Select all that apply
TikTok
Instagram
Podcast
Referred by a Friend
16
How Soon Are You Wanting Support?* This field is required.
ASAP
We're willing to wait, but sooner than later
We're not in any rush
17
Important — Please Read Before Submitting* This field is required.Booking a consultation is the next step when you’re ready to move forward together. Once you submit your application, you'll be redirected to schedule a free, 45-minute consultation to determine if or how we can best support you. If you need to coordinate scheduling with your partner, simply save the booking link to return to.
We’re ready — we’ll book our consultation as our next step
We want to book and just need a short window to coordinate schedules
We’re interested but not ready to book a consultation just yet
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