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Next Step: Explore Bravely Couples Coaching Intake Form

Welcome to The Brave Work - Together

This process requires honesty, ownership, and willingness from both partners.

Each partner should complete this form independently. The second partner will be able to restart the form and complete it after the first partner completes the form.

Click the button below to start.

Start

Question 1 of 25

1. Basic Information

 

Partner Full Name:

Email:

Phone Number:

Length of relationship:

Dating/Engaged/Married:

Children (if applicable):

Pets:

Question 2 of 25

How did you hear about Explore Bravely?

Question 3 of 25

2. Why You're Here

 

What led you to seek coaching at this point in your relationship?

Question 4 of 25

Why now? What made this feel urgent or necessary?

Question 5 of 25

3. Relationship Snapshot

 

How would you describe your relationship currently?

 

(Brief but honest)

Question 6 of 25

 

What is working well in your relationship right now?

Question 7 of 25

Where are you struggling the most in your relationship?

Question 8 of 25

4. Core Challenges

(Select all that apply)
A

Communication issues

B

Conflict/arguments

C

Emotional disconnection

D

Trust/betrayal

E

Intimacy (emotional or physical)

F

Life direction misalignment

G

Stress/external pressures

H

Other:

Question 9 of 25

Describe a recent conflict that represents your pattern.

Question 10 of 25

5. Patterns & Responsibility

 

What patterns do you notice in your relationship?

(e.g., pursue/withdraw, avoidance, escalation, shutdown, etc.)

Question 11 of 25

What role do YOU believe you play in these patterns?

(This is critical- focus on your ownership)

Question 12 of 25

6. Avoidance & Truth

 

What conversations are you avoiding in your relationship?

Question 13 of 25

What feels hardest to say to your partner right now?

Question 14 of 25

7. Past Efforts

 

What have you tried to improve your relationship?

(Select all that apply)
A

Couples therapy

B

Individual therapy

C

Books/podcasts

D

Workshops

E

Nothing consistent

F

Other:

Question 15 of 25

What helped? What didn't?

Question 16 of 25

8. Commitment & Readiness

 

On a scale of 1-10, how committed are you to improving this relationship?

Question 17 of 25

What concerns or hesitations do you have about this process?

Question 18 of 25

9. Strengths as a Couple

 

What has kept you together up to this point?

Question 19 of 25

What do you still appreciate or value about each other?

Question 20 of 25

10. Vision for the Relationship

 

If/when this coaching is successful, what will be different in your relationship?

Question 21 of 25

What does a strong, connected partnership look like to you?

Question 22 of 25

11. Accountability & Coaching Fit

 

What do you need from me as your coach to challenge and support you effectively?

Question 23 of 25

Are you both willing to be challenged, take ownership, and have difficult conversations?

Question 24 of 25

12. Final Reflection

 

Why is this relationship worth fighting for?

Question 25 of 25

Is there anything you haven't said yet that feels important?

 

If you are the first partner to complete this intake form, please click submit below and on the completion conformation screen have second partner click on Restart and complete this intake form. If you are the final partner to complete this form click submit below and move onto Step 3 as a couple.

Confirm and Submit