Group Program Discovery Form
This is a group program which includes an online course, workbook/worksheets, private zoom/call sessions AND weekly REQUIRED group zoom sessions.
Email *
Full Name *
Partner's Full Name *
Partner's Email *
This is a program designed to help couples in monogamous relationships.
If you are not in a monogamous relationship - there may be alternate program options for you in the future.
What is your (as a couple) current relationship status? *
How long have you been together? *
If married - How long have you been married?
If separated- How long have you been separated?
Do you have any children? *
If Yes - What are their ages?
If Yes - Anything about the children that you would like to share?
Have you (or your partner) have any therapy/counseling in the past? *
Required
Is there anything about that therapy/counseling you or your partner would like to share?
Please rate the following topics on the level of disagreements / arguments they cause within the relationship.
0 = No issues at all | 10 = Major issue
Religion / Spiritual Beliefs *
No issues at all
Major issue
Politics *
No issues at all
Major issue
Household Responsibilities *
No issues at all
Major issue
Money *
No issues at all
Major issue
Parenting *
No issues at all
Major issue
Jealousy / Adultery *
No issues at all
Major issue
Extended Family / In-laws *
No issues at all
Major issue
Is Domestic Violence an issue in your relationship? *
Is addiction an issue in your relationship? *
Please Explain your Current reasons for seeking this Program. *
Program Commitment
During these 30 days we are asking all couples to put as many things as possible "on hold" to focus on this program. Treat this program as if it is a Couple's Retreat with homework that you can participate in while still working and raising the kids. This means - ANYTHING you can reschedule for 30 days into the future - please do so. Non-Emergency Doctors and Dentist appointment, work and school meetings, sports - playing, attending or watching, any social gatherings, TV shows, alcohol and drug consumption and any independent activities/hobbies that are not part of the program.

We encourage all our couples to take these 30 days to start shifting from what you feel you "Should" do and move into what you "Want" to do. Now this doesn't necessarily mean skirting your responsibilities, but rather, finding ways to turn your "shoulds" into "wants".
(Please read above before answering) Do You AND Your Partner agree to FULLY Commit to 30 Days of consistent work with this program? *
Do You AND Your Partner agree to attend at least 80% of the group zoom sessions? *
How ready are YOU to make a change? *
Not Ready/Willing
Absolutely Ready
How ready is YOUR PARTNER to make a change? *
Not Ready/Willing
Absolutely Ready
What else would you like to share with us?
What questions do you have for us? *
What is Your Phone Number? (Your number will be kept private. This will only be used if we need to get in touch with you or for our private sessions) *
What is Your Partner's Phone Number? (Your number will be kept private. This will only be used if we need to get in touch with you or for our private sessions) *
Prioritizing the Program
A copy of your responses will be emailed to the address you provided.
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