Client Application
Hello, I look forward to getting to know about you and your goals in this application to become a client. Please answer honestly and thoroughly.

Should the goals you're looking to achieve align with my specialty areas, I'll reach out for us to schedule a free Meet & Greet session for us to assess personality fit.

Best,
Savannah
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Email *
Full Name *
Cell # *
City, State, Zipcode *
How did you find The Mod (Google search, referral, facebook, instagram, etc.)? *
Required
Please check off your relationship status below *
Do you (and/or your partner) have any kids? *
If you have kids, please list the following for each child 1. Name 2. Age 3. Whether the child has unique needs that puts strain or challenges the relationship (yes/no answer is fine) *
Please check off which describes your relationship history/what is currently occuring *
When was Discovery/Disclosure Day (if you have porn/sex addiction or cheating in your relationship)
MM
/
DD
/
YYYY
If you are the addict, when was the last time you engaged in masturbation, pornography, pornography substitutes, or real life interaction?
Have you gotten any type of help, if so please check them off *
Required
If you marked any of the above, please list with whom you've gotten help with, when, and the duration of your time working together *
What led to you filling out this application to become a client at The Modern Mr. and Mrs. versus other options? *
What about right now made it the right time to get coaching? *
What are the biggest issues you are struggling with right now? *
What are your top 5 goals you'd like to achieve in coaching? *
What have you tried in the past that was not effective or didn't work to achieve your goals? *
Do you need Sliding Scale? *
Which type of coaching are you looking for in our time together? (check all that apply) *
Required
Does anyone in the relationship have any neurodiversity that impacts the relationship? (i.e. autism, adhd, etc.) *
If you or your partner have any mental health struggles, you acknowledge that you have a therapist to address those mental health issues in tandem with coaching services or have completed therapy to address those challenges *
Do you have any questions that I can answer for you right now? *
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