First Name (required)

Last Name (required)

I am a: ManWoman

Email Address (required)

Phone Number: (required)

City & State or Country: (required)

Time Zone: (required)

The Best Time For Me To Dedicate Up To 2 hours For A Session Is: (required)

—Please choose an option—Week Day MorningWeek Day AfternoonWeek Day EveningWeek End MorningWeek End AfternoonWeek End Evening

How Did You Hear About This Offer? (required)

—Please choose an option—A Friend Sent MeCraigslistFacebookLinkedInMeetupPinterestTwitterYouTube-- Other

What Is Your Profession: (required)

Why Did You Choose That Profession: (required)

What Is Your Yearly Income: (required)

$0 - $15,000$15,001 - $30,000$30,001 - $50,000$50,001 - $100,000$100,001 - $250,000$250,001 - $500,000$500,001 - $1,000,000$1,000,001 - $5,000,000$5,000,001 - $10,000,000$10,000,001+

When Was Your Last Date: (required)

When Was Your Last Relationship And How Long Was It? (required)

How Long Was Your Longest Relationship? (required)

What Are Your Relationship Goals For The Next 12 Months? (required)

On A Scale of 0-10, How Important Is It For You To Overcome Your Challenges And Achieve Your Goals Today? (required)

—Please choose an option—12345678910

What Do You See As The Major Challenges Holding You Back From Getting The Relationship You Want? (required)

What’s Your #1 Biggest Challenge With Dating And Relationships? (required)

On A Scale of 0-10, How Strongly Do You Feel About This Statement: "I would LOVE to solve these challenges forever!" (required)

—Please choose an option—12345678910

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