Are you and your spouse in agreement with receiving coaching and help for your marriage?
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Yes
No
What have you done to try to fix your marital issues within the last 12 months?
*
Your name
*
First Name
Last Name
Spouse's name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Are you and your spouse currently strongly contemplating separation or divorce?
*
Yes
No
What is the greatest challenge in your marriage?
*
On a scale of 1-5, how satisfied are you in marriage?
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1
2
3
4
5
Very Unsatisfied
Very Satisfied
1 is Very Unsatisfied, 5 is Very Satisfied
How committed are you to changing your marriage? Meaning you are willing to commit to time, resources, and full effort to change things for the better.
*
1
2
3
4
5
Not Really
Extremely Committed. My marriage is worth it!
1 is Not Really, 5 is Extremely Committed. My marriage is worth it!
What's the biggest thing you feel is lacking in your marriage that if solved will bring you into alignment with your marital goals?
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Effective communication
Emotional Intimacy
Conflict resolution
Sexual Intimacy
Friendship
Other
As detailed as you can be, please describe how this issue is affecting your marriage.
*
What are the top 3 things you need help with in your marriage?
*
What are the top 3 things that are working well in your marriage and why?
*
Why do you want to work with Shivonne in her Marriage Incubator Mastermind? What can she help you with? What draws you to her work specifically?
*
All coaching is based on biblical principles - is this okay with you?
*
Yes
No
Is there any substance abuse in your marriage? If "Yes"Please Elaborate. If "No" write "N/A"
*
Is there any domestic violence abuse in your marriage? If "Yes"Please Elaborate. If "No" write "N/A"
*
Have you or you spouse ever been diagnosed with any mental health concerns/diagnoses ? If "Yes"Please Elaborate. If "No" write "N/A"
*
If yes, is said person receiving support from clinical mental health care professional
*
Yes
No
N/A
Is there anything else you think Shivonne should know?
*
Refundable Deposit
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MARRIAGE INCUBATOR MASTERMIND REFUNDABLE DEPOSIT
$
500.00
This application requires a deposit. Once you make your REFUNDABLE deposit, you will be sent an email with information on your next step. The deposit holds your spot in the mastermind and will be returned within 48 hours if either of us deems the mastermind is not a good fit.
Total
$
0.00
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