First Name *

Last Name

Email *

Phone *

Choose the biggest issue you face currently *

Communication Issues
I had (or are still having) one or more affairs
They had (or are still having) one or more affairs
Stop my divorce
Rebuild Trust
Crisis - Not infidelity
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Is your partner willing to work on things with you? *

Yes
No
Not sure
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Have there been any injuries to the relationship? List those here:

Are you able and willing to invest in yourself and/or relationship? *

Yes - I have cash or credit to invest in myself
No - I don't have cash or credit to invest in myself
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Relationship Status *

Married
Separated
Divorced
Engaged
Dating
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What's your current occupation and how long have you been doing it? *

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