Get Started with Kickass Couples Coaching

Name(Required)

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Name of partner

First Last

Marital Status(Required)

Email(Required)

Phone(Required)

Where do you live?(Required)

United States

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Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Length of time in current relationship?(Required)

What do you hope to accomplish through coaching?(Required)

What have you already done to deal with the difficulties?(Required)

What are your biggest strengths as a couple?(Required)

What role does "Commitment" play in your relationship and how committed are you to building it back up?(Required)

How important is "Communication" in your relationship and in what ways do you communicate together?(Required)

How do you handle "Conflicts" that arise together and what does the outcome usually look like?(Required)

Rank order the top three concerns that you have in your relationship with your partner. (1 being the most problematic):

1.(Required)

2.(Required)

3.(Required)

Close your eyes and picture what your perfect relationship looks like. Visualize the love, the trust, and the passion that you desire. Now, take a deep breath and remind yourself that this dream can become a reality. What does your relationship nirvana paradise look like?(Required)

Out of the 14 pillars listed below, which one(s) do you believe needs the most mending in your relationship and why?(Required)

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