Application
Blending Hearts - Couples Coaching Application Questionnaire

Helping couples in second marriages, blended families, or those healing from previous relationships build healthy, lasting connections.

Please complete this form if you are interested in free couples group or couples one on one coaching.

1. What is your current relationship status*
2. Is this your first marriage/relationship?*
3. Do you or your partner have children from a previous relationship?*
4. How long have you been together?*
5. What are the top challenges you and your partner face? (Check all that apply)*
6. How would you describe your current relationship satisfaction on a scale from 1 to 10 (1 being very unsatisfied, 10 being very satisfied)?*
7. How open are you and your partner to working on your relationship through coaching?*
8. What do you hope to gain from coaching? (Select all that apply)*
9. How soon are you hoping to start coaching?*
10. Is there anything else you would like to share about your relationship, challenges, or goals?*
11. How did you hear about Blending Hearts?*
12. Which is your preference?*
13. Do you agree to be added to our newsletter?*