Relationship Coaching Intake
Are you ready to create the lasting change in your relationship for you and your partner to be happy, fulfilled and thriving? Thank you for taking the time to tell us a bit more about you...And please note, all information contained herein is confidential.
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Email *
Name of primary contact *
Primary contact cell phone number *
Your partner's name *
Your partner's email address *
Your partner's cell phone number *
Address *
Are you...
Do you have children? 
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If yes, what are their ages? (If this is a post-divorce relationship, please specify whose children are whose.)
Please check the areas in your relationship in which you and/or your partner are feeling stuck, unhappy or dissatisfied (choose as many as applicable, and still check the box even if only one of you is experiencing a challenge in this area) *
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Please expand, if you'd like, on any checked box from above...
How long have you felt stuck? *
What have you done so far to work towards creating change? *
If you have done some work on your challenges (therapy, self-help, etc...) what has been helpful? And what hasn't been helpful? *
Do you believe that growth and change are possible? *
Please share any additional information you'd like us to know in working with you *
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