BraveCouple Questionnaire

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

Your Personal Information

Name *

First

Last *

Last

Email Address *

Phone Number *

City *

Your Age * Under 18 18-24 25-34 35-44 45-54 55-64 65 or Above

Your Spouse's Information

Spouse's First Name *

First

Spouse's Last Name *

Last

Your Spouse's Age * Under 18 18-24 25-34 35-44 45-54 55-64 65 or Above

Your Relationship

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) 1 2 3 4 5 6 7 8 9 10

How CONFIDENT are you both in your relationship right now (scale of 1-10) 1 2 3 4 5 6 7 8 9 10

How SATISFIED are you both in your relationship right now (scale of 1-10) 1 2 3 4 5 6 7 8 9 10

How did you hear about Philip *

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

If you are human, leave this field blank.