Book your Initial Coaching Call and Start Fighting for Your Family!

Duration: 45 minutes
Date:
Time:
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Name: *
Email: *
Cell Phone: *
fight_for_your_family.jpg
How many years have you been married? 
{"type":"text","name":"Family_MarriedYears","width":20,"value":"","size":"Normal","validation":"TN","validationMessage":"Please fill in this item.","placeholder":"Yrs"}


How many children do you have?
{"type":"text","name":"Family_Kidz","width":20,"value":"","size":"Normal","validation":"TI","validationMessage":"Please fill in this item.","placeholder":"Kids"}


Are you living in the same house? 
{"type":"radio","name":"Family_SameHouse","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please fill in this item.","options":"No\nYes"}


Are you wearing your wedding ring?
{"type":"radio","name":"Family_Ring","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please fill in this item.","options":"No\nYes"}


Have you watched any form of pornography in the last 90 days? 
{"type":"radio","name":"Family_Porn","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please fill in this item.","options":"No\nYes"}


Has there been any form of abuse in you marriage? 
{"type":"radio","name":"Family_Abuse","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please fill in this item.","options":"No\nYes"}


Do you currently or have you previously struggled with any form of addiction (drugs, alcohol, etc.)? 
{"type":"radio","name":"Family_Addiction","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please fill in this item.","options":"No\nYes"}


How many times have you (husband) been married including this marriage? 
{"type":"text","name":"Family_TimesMarriedHim","width":20,"value":"","size":"Normal","validation":"TP","validationMessage":"Please fill in this item.","placeholder":"Yrs"}


How many times has she been married including this marriage? 
{"type":"text","name":"Family_TimesMarriedHer","width":20,"value":"","size":"Normal","validation":"TP","validationMessage":"Please fill in this item.","placeholder":"Yrs"}


What is the current biggest problem in your relationship? 
{"type":"textarea","name":"Family_BiggestProble","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":200,"placeholder":"Biggest problem in relationship"}


How are things going in other areas of your life (finances, health, work, etc.)? 
{"type":"textarea","name":"Family_OtherAreas","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":200,"placeholder":"How are things in the other areas of your life? "}


Did you watch my webinar?
{"type":"radio","name":"Family_Webinar","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please fill in this item.","options":"No\nYes"}


What did you learn from my webinar that helped you decide to schedule this call?
{"type":"textarea","name":"Family_WebinarLearn","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"Describe what you learned from my webinar"}


On a scale of 1-10 how willing are you to fight for your family?
-1-I'm done fighting2345-Some days I want to fight other days I want to quit678910-I will do whatever it takes to fight for my family{"type":"select","name":"Family_Motivation","width":100,"value":"","size":"Normal","validation":"N1","validationMessage":"Please fill in this item.","options":"-\n1-I'm done fighting\n2\n3\n4\n5-Some days I want to fight other days I want to quit\n6\n7\n8\n9\n10-I will do whatever it takes to fight for my family"}


I will call you at the time you've chosen. Please commit to your appointment by checking the box below:

{"type":"checkbox","name":"Family_CommittoCall","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please fill in this item.","options":"Yes, I promise I will answer the phone when you call"}