BraveCouple Questionnaire

PLEASE NOTE: Your answers will be kept confidential and will not be shared.

Name *

First

Last *

Last

Email Address *

Phone Number *

City *

Your Age *

Spouse's First Name *

First

Spouse's Last Name *

Last

Your Spouse's Age *

Why are you interested in the BraveCouple Retreat? *

What are the greatest challenges in your relationship is at the moment? *

What would you like to improve about your relationship? *

How HAPPY are you both in your relationship right now (scale of 1-10)

How CONFIDENT are you both in your relationship right now (scale of 1-10)

How SATISFIED are you both in your relationship right now (scale of 1-10)

How did you hear about Philip *

Is there anything else you would like to add that you feel is important?

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