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This form takes about one minute to complete. Answer all the questions accurately. After you submit, you can book a call where we’ll review your situation and plan your next steps.
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About Your Situation
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Married (Living Together Or Separated)
Divorced
Engaged
In A Relationship (Boyfriend-Girlfriend)
Other
Current relationship Status
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No
Yes
I Don't Know
Is she seeing someone else?
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Good
Ok
Bad
What terms are you on with her?
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We Live Together
We Don't Live Together
What is your current living situation?
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Absolutely important — my top priority
Not very important
How important is it for you to fix things with her?
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Just hurting a bit
Absolutely crushed, confused, anxious, and in pain
I’m actually okay
How are you doing emotionally?
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It would devastate me / change my life
Not that much
If she leaves for another man, never comes back, and you’re left with regret, anxiety, and no understanding of how to make her feel emotionally safe, how would that impact you?
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Yes, I’m ready to go all in and invest to get full the full support and the best results ($5K–$15K range)
I can invest at least $2k to get help
No, I’m not ready to invest
My coaching programs are for men ready to make a serious investment to save their marriage. If accepted, would you be prepared to commit financially?
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What Do You Do For Work
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Your Contact Info
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First Name
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Last Name
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Mobile Number
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Email
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Make sure all your information is correct so I can contact you and go over your situation. All information submitted here is 100 percent secure.
If you need help, message me: (516) 234-7249
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