1:1 Intensive Name: First Last Email: Phone:Age:What are you seeking support and guidance for a this time?Have you and your partner done any previous couples work?If yes, please briefly describe what, when and where?If you have previously tried other therapeutic approaches? Please share what worked and what didn’t?How aware are you of your own parts that play a role in your relationship dynamic?What do you hope to accomplish, learn, and heal through this intensive immersion?Are you currently on any prescription medication? If yes, please list what they are, the dose, and for how long.Understanding the importance of the questionnaire form, we'd like to know how committed you are to completing it once your application is approved. Please be aware that filling out this form is a mandatory requirement for approval. If you face any difficulties in doing it independently, we can provide one-off sessions to guide you through the process. This step plays a crucial role in establishing a safe and supportive environment, ensuring the best possible outcome for your immersion process.How committed are you to coming into this experience with an open heart and mind?Is there anything else you would like to share with me that you feel is important for me to know about you at this time?EmailThis field is for validation purposes and should be left unchanged.
