We're so honored to have you as a client. Please take a moment to tell us a little bit about yourself by filling out this survey.

Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday

MM

DD

YYYY

Relationship Status

Single

Married

Divorced

In Relationship

How many years have you been together?

Children?

Yes

No

If yes, how many?

What is your biggest personal challenge in your relationship?

What is your partner's biggest challenge in the relationship?

What is the biggest hurdle in your relationship you just can't seem to get past?

Do you feel the trust between you and your partner is intact?

If you could create anything you wanted in your relationship, what would it be?

Tell us a little about yourself. What do you like to do for fun?

What makes you laugh?

What is your favorite thing about your partner?