Couples Inquiry -15min FREE - Restored Mentoring

Name: *
Email: *
Cell Phone:
Time Zone:
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Thank you 's for contacting Restored Mentoring! 

You are considering couple's betrayal recovery counseling. This step alone is HUGE and takes a lot of courage to reach out when you know you cannot do it on your own anymore. We applaud your bravery and know you are in a place of pain and need to seek our help for something so intensely personal. We honor that!  Everything we discuss and all online forms are completely confidential. 

We will be in touch with you within the next few days to schedule your free 15 minute phone consultation.  The purpose of this is to see if we are good fit for each other.  If after our conversation, you choose to enroll as one of our clients, we will provide the necessary links to begin the process and the password for the client-only area of our website.

Just a few more questions...

His Name 
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His Age
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Her Name
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Her Age
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Years Married
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Why are you reaching out to us?
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How did you hear about us?
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Are you currently facing or expect to face any legal crisis? (criminal charges, work investigation, divorce or custody hearings, etc. ?
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Briefly, what is the concern that you are dealing with that has you exploring mentoring/counseling?
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 Let's connect
I will want to reach out and speak with you. Let me know a good number and good time

cell phone- pick one partner to be the point of contact
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Is there a day of the week or time of the day during the normal business day which works best? or one that doesn't work for our 15 minute call?
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We will typically respond by email to arrange our phone call. If you have special circumstances please let us know.


We look forward to speaking to you!