This application serves as my first introduction to you, so take your time and put your heart and soul into it. After all, this is your life you're choosing to transform. And these questions are an opportunity for you to get powerful clarity on where you are at and where you want to go.

It usually takes about 20 minutes to complete the form. Upon receipt of your application, someone from my team will email you within 48 hours.

— Jeffrey
Begin
 
What is your full name? *

 
What is your best email address? *

 
How did you find me? *

 
Where do you live? *

 
How old are you? *

 
What is your relationship status? *

 
What is your U.S. phone number (If you are international, include your FaceTime and/or Skype ID.) *

 
What do you currently do for work or business? *

 
Are you willing to share openly and honestly about your life? *

 
What specific circumstances have you reaching out for coaching? Why now? (Be as detailed as possible.) *

 
What do you think is possible for you if you made major breakthroughs and took consistent action toward creating the dating & relationship life you want? *

 
How long have you been actively working to improve this area of your life? *

 
What actions have you already tried to attempt to improve your dating life? What worked? What didn't work? Why do you believe they haven't worked for you yet? (Be as detailed as possible.) *

 
How is your physical health? (Energy, body, strength, diet) *

 
How is your social life? (Friendships, social activities, family, community) *

 
How is your career/business? (Where are you now and where are you headed professionally? Are you doing what you love to do? ) *

 
How is your financial health? (Income/revenue, savings/investments, debt. No need for exact numbers, but please provide an overview.) *

 
How is your self-care? (What daily or weekly practices help keep you centered and in touch with your inner guidance and power?) *

 
Are you currently under the care of doctors or therapists for any conditions? (List both medical and psychological treatments.) *

 
Are you aware that coaching is not a substitute for psychotherapy or professional medical treatment? *

     
 
What best describes your situation?
*


 
Do you have any hesitations about this opportunity? *

 
If you are a right fit for coaching, how serious are you about stretching yourself and investing resources (time + effort + energy + finances) into your personal development? *

 
How will you know if you're receiving value from working with me? What outcomes would make this investment worth it? *

 
Anything else you want me to know?

 
Thank you for your application. No matter what happens from this point, from my heart to yours, I salute your courage in taking the first bold step to creating the life and relationship you truly want. And I am looking forward to seeing if or how I can support you.

- Jeffrey

(P.S. Be sure to continue and click "Submit Application" below!)

 
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