📍Pre-Insight Call Questionnaire

Please fill out this form honestly and thoughtfully.

This will help us get the most out of our time together.

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Email *
Relationship Status: *
What patterns in dating & relationships are you tired of repeating?
(Be brutally honest. What keeps happening that you know needs to change?)
*
Can you tell me how these patterns are affecting your daily life and your ability to connect with others? *
If there's one thing you'd hope Jeremie could help you achieve, what would that be?
*
What kind of support do you feel is missing in your life when it comes to relationships?
(Do you struggle with guidance, accountability, or real masculine insight?)
*
Are you currently interested in having ongoing personalized support, structure, and accountability ?
*

As we explore this work together, it's important to also talk about the investment involved.

Our private mentorship packages typically range from $500–$3,500(with installment options) If its a HELL YES for both of us are you ready to make this kind of investment in yourself?

*
Anything else you'd like to share with Jeremie?
A copy of your responses will be emailed to the address you provided.
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