Full Name *

Phone

Email *

By checking this box, I consent to receive non-marketing text messages from Beyond Breath about appointment confirmations, scheduling updates, reminders, and information related to my application and A Way Back Call. Message frequency varies. Message and data rates may apply. Text HELP for assistance. Reply STOP to opt out.

Which best describes where you are right now? *

I want my marriage, but I don't know how to move past what happened.

I hope my marriage can work, but I'm still unsure whether staying is right for me.

My husband is doing the work, but I still can't relax or trust what I'm seeing.

My husband isn't doing the work I wish he would, and I'm exhausted from letting his choices consume me.

I've decided to leave/end my marriage and primarily need support through the separation.

Something else.

If we worked together and the next 90 days changed your life, what would be different? *

Which statement feels most true right now? *

I need my husband to change before I believe I can feel okay.

I know I can't control what he does, but I don't yet know how to stop his choices from controlling my life.

I'm ready to focus on my own healing even if I don't know what my husband or marriage will ultimately do.

I'm mainly looking for someone to tell me whether I should stay or leave.

Why does changing this feel important to you now? What happens if nothing changes over the next year? *

How ready are you to do the work required to change your own experience—even if your husband doesn't change alongside you? *

I'm ready. I can't keep living like this.

I'm scared, but I'm ready for something to change.

I'm interested, but I'm still mostly exploring my options.

I'm hoping to find something my husband and I can do together.

I'm primarily looking for help getting my husband to change.

If we both decide this is the right fit, are you in a position to invest financially in getting the support you need? *

Yes — I'm prepared to invest in the right support.

Yes — but I would likely need a payment plan.

Possibly — I'd need to understand the program and investment first.

No — I'm not currently in a position to make a significant investment.

If you decide this is the support you want, is anyone else involved in the financial decision? *

No, I can make this decision myself.

Yes, I'll want to talk with my husband.

Yes, someone else is involved.

I'm not sure.