First Name *

Last Name *

Email *

Street Address *

City *

State / Province *

Postal / Zip Code *

Phone Number *

Challenges/Goals

Please answer as descriptively as possible

What's the #1 Challenge/Goals you want to accomplish (if we accomplish) would make you 100% satisfied with your investment? *

Make this a tangible goal: (For example - stop looking at his phone; stop ruminating about the future; sleep through the night without nightmares; release anxiety and panic)

List up to 5 other challenges/goals that you want me to help solve during the duration we work together *

Please list tangible things that we can measure and track..

What are the 3 month, 6 month, and 12 month goals for your marriage? *

Background Information

Answer this thoroughly, please!

What have you done to try to overcome your husband’s infidelity, and for how long have you been attempting it? *

What symptoms are you experiencing physically, mentally, emotionally, and spiritually because of this situation? *

How long have you and your partner been together? *

Describe your current day-to-day interactions with your husband. *