Full Name

FIRST LAST

Phone *

INCLUDE COUNTRY CODE

Email *

City /State /Country

What is the current state of the relationship?

How long have the two of you been in a relationship

1-3 years

5-7 years

7-15 years

15+ years

What led you to consider a retreat at this time?

What are the biggest challenges you are currently facing as a couple? (Check all that apply)

Communication

Repeated Conflict

Emotional Disconnection

Intimacy

Betrayal / Trust

Life Transitions

If nothing changes where do you feel the relationship will be in 1 year?

What would a successful outcome from this retreat look like for you?

What do you most want to feel differently in your relationship?

Safety in communication

Connectedness

Feel heard/understood

Respected

Desired

Are both partners committed to attending and participating in this RESET?

Yes

No

Unsure

Have you previously participated in couples counseling or coaching?

Yes

No

Our RESETS begin at $12,500 per couple. Are you prepared to invest in this experience if it feels like a right fit?

Yes

No

Are there any current concerns we should be aware of before working together?

Is there anything important about your relationship, background, or culture that you would like me to understand?

Have you experienced a wellness retreat before?

YES

NO