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Couples Mediation

You’re here, because deep down, you’re ready for a change in your relationship.
The change itself, could be anything, but the outcome will always be a step closer to you finding your happiness.
Life is too short to not be happy. Say yes to happiness!

For *FREE* services, would you be willing to allow some parts of your experience with our sessions, to be filmed or recorded for marketing purposes? *

Yes
No

By selecting Yes, you are giving me permission to use the video/audio for marketing on my social media platforms.

What services are you interested in? *

Couple's counseling
Couple's mediation
Relationship coaching
Couple's makeover / weight loss

I am inquiring about services *

without my person's knowledge
with my person's knowledge
with my person here right now

Have you ever hired a coach, therapist, or counselor to assist with these services before? *

No, I'm new to this
Not yet, I haven't found the right outlet
Yes

In general, what are the issues in your relationship? *

Past trauma
Infidelity
Poor communication
An ex
Family
Finances
Depression
Health / weight
Alcoholism / Drugs
Stuck in same routine
Sex
A disagreement

Your name *

First

Last

Your person's name *

First

Last

How long have you been together? *

Less than a year
1-3 years
4-6 years
6-10 years
10-15 years
15-20 years
20+ years

We are *

Married
Not married
Engaged
Living together
Not living together

Your phone number *

Your email *

State *

Zip code *

Your age *

Your partner's age *

Your gender *

Your partner's gender *

Your orientation *

Your partner's orientation *

I'm... *

Out of the closet
Mostly out of the closet
Partially out of the closet
In the closet

My partner is... *

Out of the closet
Mostly out of the closet
Partially out of the closet
In the closet

Relationship dynamic *

Monogamous
Polyamrous
Polygamous
Polygynous

When it comes to trying new things, generally I'm... *

not really interested
hesitant, but may give it a try
open to trying new things, sometimes
very open and ready to do it

In a conversation, I'm usually... *

listening the most
waiting to speak
speaking the most
listening and speaking evenly

Do you believe that being courteous, such as saying "thank you" or holding a door, is important even when the other person involved does NOT deserve it? *

Yes, kill them with kindness
In some cases, maybe
I treat them how they treat me
No

Specifically, what brings you here, what's going on in your relationship? *

How long have you been dealing with the issue above? *

Less than 1 year
1-3 years
4-7 years
8-15+ years

Are you completely ready to commit to a resolution for your problem? *

Yes, I'm ready!
I'm hesitant, but it needs to be done
I need your services to hold me accountable, I may back out

By selecting "Yes" to agreeing to having your experience documented or filmed in exchange for free/discounted services, this means that you are granting me permission to use the audio/video for marketing purposes on my social media platforms. This is not a gaurantee that it will be filmed or posted online, this just serves as a release, just in case it is used. *

Yes, I understand and I give you permission to document our sessions to use for marketing

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