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 1818-2425-3435-4445-5455-6465 or Above Your Spouse's Information Spouse's First Name * First Spouse's Last Name * Last Your Spouse's Age * Under 1818-2425-3435-4445-5455-6465 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) 12345678910 How CONFIDENT are you both in your relationship right now (scale of 1-10) 12345678910 How SATISFIED are you both in your relationship right now (scale of 1-10) 12345678910 How did you hear about Philip * Is there anything else you would like to add that you feel is important? Δ