Application:  Relationship Reset and Rebalance Program
Application for Relationship Reset and Rebalance Coaching Program with
Karyn Spetz, LCSW, Couples Therapist and Relationship Coach
Sign in to Google to save your progress. Learn more
Email *
First Name *
Last name *
E-mail *
How long have you and your partner been together? *
What are the main challenges you're currently experiencing in your relationship? *
How long have you been dealing with this problem? *
How would your relationship change if you felt more comfortable speaking up in your relationship? *
The investment for the coaching program is $997.  If you are accepted into the program are you able to afford this in either one payment or a multiple payment plan? *
Are you currently able to schedule weekly sessions for the next 8 weeks?  *
Required
Is there anything else you'd like me to know about your current situation?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of A Better Relationship Coaching.

Does this form look suspicious? Report

Google Forms