Consent *

I understand that the information that I provide to Motivating Marriages Psychology via this online application form remain confidential and will not be shared with any third parties

I understand that Marathon Therapy is held over two consecutive days and fees begin at $4500

For more information on the format and costs of Marathon Therapy please see the Marathon Therapy page on our website.

Yes

Partner 1 Name *

First Name

Last Name

Mobile

(###)

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Partner 2 Name

First Name

Last Name

Mobile

(###)

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What issues are you facing in the relationship?

Please tick as many as are applicable

Regular conflict

One or both of us don’t feel understood

One or both of us are feeling attacked and blamed

One or both of us are feeling belittled

Our arguments are very heated

Our arguments involve a lot of nastiness

We never seem to be able to be able to resolve or reach a compromise in our disagreements

There is emotional abuse in our relationship

There is physical violence in our relationship

There is alcohol abuse in our relationship

There is drug abuse in our relationship

We have grown apart

We don’t share the same goals or dreams for our future

We don’t know each other anymore

We have very little/no physical intimacy or sex in our relationship

There is little trust in our relationship

One or both of us have emotionally withdrawn from our relationship

One or both of us have thought about ending our relationship

There has been infidelity by one or both of us