RelationSHIFT Breakthrough 911 Application
In order to be accepted into the RelationSHIFT Breakthrough 911 in-home relationship rescue program, please have both partners fill out this application. We are committed to giving you our very best and want to make sure you and your partner are ready and a good fit for this program.
* Required
Email address
*
Your email
Applicant's Name & age
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Your answer
Email
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Your answer
Phone number
*
Your answer
Address
Your answer
Do you have a Skype account and if so, what is your Skype address?
Your answer
Do you have Apple FaceTime on a phone or iPad?
Your answer
What is the name of your closest airport:
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Your answer
Partner's Name & age
*
Your answer
Email
*
Your answer
Phone number
*
Your answer
Address
Your answer
Length of time in partnership/marriage:
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Your answer
Describe your relationship status currently:
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Your answer
Do you have children & what are their ages?
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Your answer
What have you already tried?
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Your answer
From your perspective, what would you say is the primary issue sabotaging your relationship?
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Your answer
If you could have the relationship all your way, what would that look like to you?
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Your answer
What prevents you from making it this way?
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Your answer
What have you already tried and what have you learned from the effort?
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Your answer
On a scale of 1-10, what level of stress are you currently living with?
Poor
1
2
3
4
5
6
7
8
9
10
Outstanding
Clear selection
On a scale of 1-10, how would you rate your current quality of your life?
Poor
1
2
3
4
5
6
7
8
9
10
Outstanding
Clear selection
By checking this box, applicant acknowledges that they are committed and willing to do their very best to find a way to turn around this relationship. Do you agree?
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Yes
No
Required
By checking this box, applicant's partner acknowledges that they are committed and willing to do their very best to find a way to turn around this relationship. Do you agree?
*
Yes
No
Required
Please share at least 3 reasons why you’re committed to making your relationship work?
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Your answer
A copy of your responses will be emailed to the address you provided.
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