Full Name *

Email *

Phone *

Relationship Status *

Married

Separated

Divorce Papers Filed

Briefly describe your current relationship situation. What’s going on? *

What have you tried already to fix things? (Therapy, books, church, coaching?) *

What’s worked — and what hasn’t? *

On a scale of 1–10, how committed are you to creating change and taking the necessary steps for recovery in your relationship — even if your spouse isn't ready yet? *

What scares you most about staying where you are right now? *

What would it mean to you if your marriage felt safe, connected, and peaceful again?

Is there any current abuse, untreated addiction, or trauma that would make this container unsafe? (We don’t judge — we need to know.) *

Yes

No

Are both partners aware of this application? (It’s okay if they’re not on board yet — just be honest.) *

Yes

No

We only accept a handful of couples each round. Why do you believe this is the right fit for you? *

If invited into the Marriage Breakthrough Intensive, are you in a position to invest time, energy, and financial resources to do this work? *

Yes

No

Are you ready to commit fully — to an 8-step process refined over 10 years — doing the work with grit and follow-through, even if your spouse struggles or steps back? *

Yes

No

Is there anything else you'd want us to know about you before we connect?

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