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.
Email address *
Applicant's Name & age *
Email *
Phone number *
Address
Do you have a Skype account and if so, what is your Skype address?
Do you have Apple FaceTime on a phone or iPad?
What is the name of your closest airport: *
Partner's Name & age *
Email *
Phone number *
Address
Length of time in partnership/marriage: *
Describe your relationship status currently: *
Do you have children & what are their ages? *
What have you already tried? *
From your perspective, what would you say is the primary issue sabotaging your relationship? *
If you could have the relationship all your way, what would that look like to you? *
What prevents you from making it this way? *
What have you already tried and what have you learned from the effort? *
On a scale of 1-10, what level of stress are you currently living with?
Poor
Outstanding
Clear selection
On a scale of 1-10, how would you rate your current quality of your life?
Poor
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? *
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? *
Required
Please share at least 3 reasons why you’re committed to making your relationship work? *
A copy of your responses will be emailed to the address you provided.
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