Full Name
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Partner's Full Name (if it applies):
Email
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Phone
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Address
City
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State
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1. What inspired you to inquire about this program today?
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2. Which option best reflects your current relationship situation?
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We're having recurring conflict.
Communication has broken down.
We're navigating a business or leadership transition.
Money or decision-making has become difficult.
Success has changed our relationship.
We're growing apart.
We want to strengthen an already good relationship.
Other
2a. Enter reason if chose other in Q2
3. If we were talking again in 3–6 months, what positive changes would you hope to see?
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4. What makes this the right time for you to focus on your relationship?
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5. Have you previously worked with a therapist, relationship coach, mentor, or similar professional?
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6. If everyone involved fully committed to creating the relationship you truly want, what do you believe would be possible?
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SUBMIT
