Womens Intake Form

About You

First Name *

Last Name *

Email Address *

Phone Number *

Your Relationship Journey

What is your current relationship status? *

Single, seeking partnership

In a relationship, wanting to deepen connection

Recently separated/divorced, healing

In a relationship with challenges

What is your primary intention? *

Attract an emotionally available partner

Heal my relationship with the masculine

Feel more emotionally secure in love

Establish healthy boundaries

Heal past relationship trauma

Become more present and authentic

Your Current Challenges

What is your biggest challenge right now? *

What patterns have you noticed in your relationships? *

How long have you been dealing with this? *

Your Desired Outcome

What would it feel like to have this resolved? *

What qualities are important to you in a partner? *

Your Coaching Readiness

Have you worked with a coach or therapist before? *

Yes, and it was very helpful

Yes, but it didn't fully address my needs

No, but I'm open to it

No, I'm new to this

How committed are you to transforming your love life? *

Highly committed - this is a priority

Very interested but have some concerns

Curious to learn more first

Are you interested in the $12,000 Coaching Container? *

Yes, tell me more

Maybe, I want to explore options

No, I'm looking for something else

Anything Else?

Is there anything else you'd like Mike to know about your situation?

Your Path to Deeper Connection