Thank you for your interest in working with me. I’m excited to get to know you better, and to help you with all your dating, mating and relating questions.

In order for us to have a productive and helpful meeting, please take a few minutes to fill out the form below. The more details you can give me, the better I am able to answer your questions.

Once you’ve filled out the questionnaire, you’ll be redirected to my scheduling app, where you can choose a time for our call that is convenient for you. All time slots are listed as 45 minutes for scheduling purposes, but your actual call length is 30 minutes.

Schedule a Coaching Call

Your Name *

Your Email Address *

Cell Phone Number *

If outside the US, you must include a Skype or WhatsApp number

Country Where You Live *

City/State/Province Where You Live *

What is your age? *

Do you have children? If so, what are their ages/gender? *

Lifestyle Question: What is your annual income? *

Under $40,000

$41,000 to $70,000

$71,000 to $100,000

$101,000 to $150,000

Over $151,000

Lifestyle Question: What is the annual income of the man with whom you want a relationship? *

Under $40,000

$41,000 to $70,000

$71,000 to $100,000

$101,000 to $150,000

Over $151,000

Lifestyle Question: What is your occupation and job title? *

Are you currently dating someone or in a relationship? *

Yes

No

If yes, how long have you been seeing each other?

What issues are you currently facing in your relationship that you need help with? *

When was your last relationship and why and how did it end? *

What if any work have you done in the area of personal growth, such as other coaching, reading self-help books. etc? *

What's your burning question for today? *

What do you feel has prevented you from finding lasting love or relationship success at this time? *

When you're in a relationship, what are your biggest fears and insecurities? *

What beliefs do you have about yourself that limit your thinking as to what's available to you in a relationship (e.g. there are no good men out there)? *

What are the two things you'd like to learn from a dating and relationship coach? *

Are you currently on one or more dating sites?

Yes

No

List the sites you use. *

Where and when did you find me? *

Right now... *

I understand that coaching requires an investment of up to $3,000 (or more), and I have the financial resources to hire a coach.

I understand that coaching requires a significant investment, and I can find the financial resources to hire a coach.

I do not have the resources to invest in coaching (even if a one-time session is $450).

Why should I consider taking you on as a client right now? (What makes you coachable?) *

Upload a Photo

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I'd love to have a better sense of who you are, and a photo can help. Feel free to upload a headshot if you like.