Marriage Intake Form

1
Are you the husband or the wife?
I'm the HusbandI'm the Wife
2
Do you have kids together?
Yes, we have kidsNo, we don't have kids
3
Do you still live together with your spouse?
Yes, we live togetherNo, we don't live together
4
Have either of you filed for a divorce?
YesNo
5
How often do you feel wanted in your marriage?
I feel wanted all the time.
I feel wanted some of the time.
I rarely feel wanted.
I never feel wanted.
6
Please select all which apply to your current situation:
My spouse won't talk to me at all (ignoring my calls, blocked texts, etc).
There is/has been an affair in our marriage.
I don’t feel connected with my spouse.
My spouse has narcissistic tendencies.
We’ve faced addiction troubles (drugs, alcohol, pornography, gambling).
One or both of us have experienced mental health like depression, anxiety, PTSD.
Nothing above applies to my situation.
7
How important is it for you to get your spouse back?
It's extremely important for me.
It would be nice.
I'm impartial.
I don't want to get back with my spouse.
8
Please select any which apply to your situation:
I have suffered severe physical abuse.
There is a restraining order in place.
Neither of these apply to me.
9
Does your spouse want to save your marriage?
Yes
No
I'm not sure.
10
If you want to share any other details, or get anything off your chest - now is a good time to put your feelings into words. It helps begin the process...
Huge
Large
Normal
Small
Ok
Ok
11
What do you miss most about your marriage?
12
If anything were possible, where would you like your marriage to be in 4 months?
13
If you achieved that, how would that make you feel?
14
What have you tried so far to save your marriage?
Counseling/therapy.
Marriage coaching.
Online courses.
Self-help (marital books, Youtube videos)
Nothing mentioned above.
15
But that didn't work?
No, it didn't workIt didn't last...
16
Which best describes your situation?* This field is required.
I have access to financial resources and I am willing to invest in saving my marriage.
I do NOT have access to financial resources to invest in saving my marriage.
17
We'd like to send you some useful information and get in contact with you to see if we can help. What is your name?* This field is required.
First Name
Last Name
18
What email address should we send the information pack to?* This field is required.
example@example.com
19
And what is your phone number?* This field is required.
Please enter a valid phone number.
20
Thank you for taking the marriage quiz.

One of our expert team will be in contact with you if they believe they can help.

Meanwhile, we are giving you a useful information pack to help you get started, you can download that on the next page.

Click SUBMIT to go to the download page.

Here's to your marriage!

The Lion Heart Marriage Team

P.S. Any marriage can be saved, and we help our clients do it by themselves - with no counseling or therapy - so when one of our experts reaches out, be sure to respond. You took this quiz for a reason. Let's work together to get your marriage back on track.
21
Lead Source
Should be Empty: