Name (s)
Email
Country
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---------------
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Virgin Islands, U.S.
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Phone Number
Please select your gender: Female
Male
What is your age?
What is your date of birth (necessary for assessments)?
My partner/spouse is: Willing and motivated to get help for our relationship!
Is not very interested in this, but is willing to participate in an initial consultation.
Is not interested, and does not want to be part of a consultation.
What is your partner's full name (N/A if not applicable)?
What is your partner's email address?
What is your partner's phone number?
What is your partner's gender?
What is your partner's age?
What is your partner's date of birth (necessary for assessments)?
Relationship Status: Long-term: 1 to 5 years
Long-term: 5 years or more
Dating less than a year
Not in a relationship
How long have you been in this relationship?
Please select one: My partner is diagnosed as autistic (formerly called Asperger's).
My partner is not diagnosed, but I suspect he or she is autistic.
I am diagnosed as autistic.
I am not diagnosed but I suspect I may be autistic.
I don't know if either one of us is autistic.
None of these apply to me.
Why is now the time for you to invest in coaching for your relationship?
How many times have you each been married prior to this relationship?
What do you hope to achieve in your relationship, and for yourself, personally, by working with me?
What have you done in the past, or are you currently doing on your own, to work through your relationship challenges?
What is your question for us today?
Of the coaching options below, which option most interests you : Comprehensive Relationship Evaluation (Autism Assessment)
1/2 Day (4-hour) Private Intensive Coaching (Virtual)
2-Hour Coaching Blocks
1/2 Day Communication and Connection Skills Training (Group/Virtual)
Private, 2-day Intensive Retreat (In Person)
3-Day Couples Retreat (In Person)
A Combination of the Above in a Coaching Package
Which statement applies the most to your level of readiness to invest time, effort and finances into a coaching program: At the moment, I'm only interested in assessment - I'm not interest in coaching right now.
I'm motivated and willing to put in time and effort into improving my life and my relationship.
I want my life to be better, but I'm not sure how motivated I am to participate in coaching.
I'm honestly not sure what I want right now. I just want to talk to you first and figure out where to go from there.
How did you hear about me: Facebook suggestion (in-line or search)
YouTube
Instagram
TikTok
LinkedIn
Your Neurodiverse Relationship Podcast
My therapist
A friend/family member
Internet Search
Other
How would you prefer that we contact you about booking your consultation? Email
Text
Phone
Any of the above
SUBMIT