This is a special session to help you get clear on where you are now and what’s standing in your way. I will share insight you can put into immediate use as well as discuss your coaching options and assess if it's the right next step for you, so you can receive a long-term transformation!

Must complete the form prior to booking session
All information is Confidential!
Today's Date *

First Name: *

Last Name: *

Phone/Cell #: *

What is your Skype ID?
ONLY For inquiries outside of the United States.

If outside the United States, what country do you currently reside?
ONLY For inquiries outside of the United States.

Your current relationship status. *

Tell me about your OVERALL relationship challenge?
What is your biggest frustration about not being in a meaningful relationship and how is it adversely affecting you?
(It's important to be SPECIFIC) *

On a scale of 1 -10, 10 being most urgent, do you want to be with your life partner / husband / soul mate? *

You want to be in a committed relationship in -- *


How long have you been single?  Or, not in a meaningful relationship? *

Select one (1)

Identify the chronic (challenging) patterns that have existed in your last 2-4 relationships. (It's important to be SPECIFIC) *

What behavior has plagued your relationships? *

What do you have a deep desire to transform so you can be in a satisfying relationship?   Do you know unfulfilling relationships and low self-confidence adversely affects your income potential *

Select one (1) - Your most pressing concern

On a scale of 1 -10, how confident are you in your sex appeal and attraction? *

Do you battle with the "Good Girl Syndrome"?  These are a set of beliefs you learned through your upbringing of how a woman should be humble, not sensual or sexual, etc. *

Which aspect of the "Man Magnet Blueprint" challenges you the most? *

What have you tried in the past to address this frustration? *

Select the one (1) that you have vested the most time, attention and money with.

What were the results of your past efforts *

Select the one (1) that you have vested the most time, attention and money with.

What did you invest in the therapy, coaching, personal development programs or retreats? (Cumulative Investment) *

Which program would you be interested in learning about? *

Select ONLY 1

Do you have a "commitment to self" mindset?  When you see you need help, you invest the time, energy or money necessary to get the help you need? *

Are you ready to put yourself first and invest the money to get the support you need? *

What have you allowed to stop you from making changes in your life? *

What are you ready to invest now to BE WITH your life partner / husband? *

Please explain if there is anyone else involved in the decision making of working with me. (spouse, parent or other family member, etc.) *

If coaching is solely your decision, indicate that below.
*How did you hear about me?
*If through another coaching colleague, click "Other" below and share their name *

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