SAVE MY LOVE LIFE QUESTIONNAIRE

Tell me about what's going on.

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Your Name *

First

Last

Age *

Partner's Name *

First

Last

City & State *

Your Email *

Age *

Time Zone *

Best Contact Number *

What do you currently like about your current relationship? *

What has been the most stressful part of your relationship? How has this impacted your relationship? *

What would you like to change about your current relationship? *

How has the stress impacted you personally? *

What have you tried or what are you currently doing now to help with the change you’re hoping for (i.e. therapy, marriage counseling)? *

What are you going to do if nothing changes for you? In the next 5 or 10 years? Are you willing to settle for that? *

How do you believe the changes you desire will help make your life and your relationship better? *

Will your partner/spouse be joining us on the initial in-take call? *

I understand this experience is free and will require a commitment from both myself and my partner to dedicate at least 1 hour for the next 8 weeks to working on our relationship. I understand that if either myself or my partner is unable to make this commitment we should not submit this form at this time. I also understand that additional charges may be applied for any additional services I/we incur. *

I acknowledge and understand the statements above and agree with these terms.

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By submitting this form you are consenting to the terms and conditions of this offer. You understand that portions or all of our calls may be recorded in order for me to collect information such as feedback on the services provided, to track and measure progress, etc. At no time will any of this information be subject to release outside of intended purposes to assist participants and/or to advertise future services and products.

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Tell me about what's going on.