APPLICATION: 6-Month Marriage Counseling
with a Money Back Guarantee

This application must be completed once by each spouse. Be sure to click 'OK' after each question.

Once the second spouse has completed the application they may follow the final instructions to schedule your interview call with Keith Dorscht.

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* 1. Applicant Details

Name *

Address *

City/Town *

State/Province *

Country *

Email Address *

Phone Number

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* 2. How many times have you been married?

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* 3. How many years have you been in your current marriage? (Enter a number)

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* 4. What best describes your marriage over the past 6 months?

Consistently cold and/or distant.

Swinging between high times that are great and low times that are hard/painful.

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* 5. In the past 6 months have you been addicted?

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* 6. Check all that apply.

Not applicable.

Illegal Drugs.

Medication/pain killers.

Alcohol.

Pornography.

Food.

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* 7. Indicate affair history. (Sexual and/or emotional)

Never

Previously

Currently

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 8. Have you and your spouse participated in couples counseling previously?

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* 9. I would like to...

Get back to a happier time in my marriage.

Discover an new level of happiness not previously experienced in my marriage.

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* 10. Rank the desires you have for couples counseling.

To see if my spouse can/will change.

To focus on and work on my issues and needs.

To know if I should stay or get divorced.

Pursue more enjoyment in my marriage.

To create a mutually satisfying relationship between my spouse and I.

'Other' that I can share during phone interview.

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* 11. If counseling started today, how honest do you think you could be?

Not at all

Fairly

Completely

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 12. If counseling started today, how open do you think you could be?

Not at all

Fairly

Completely

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 13. Explain why you chose that scale point in the previous question.

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* 14. How important do think accountability is for you to get the most from counseling?

Not at all

Important

Very Important

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 15. How important to you is the Money Back Guarantee?

Not at all

Important

Very Important

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 16. When would you be available to begin the 6-month Marriage Counseling with a Money Back Guarantee?

In 1-7 days.

In 8-14 days.

In no hurry.

IMPORTANT: Before You Click 'DONE'
(scroll below)

Click this link to open a new tab/window:

www.CounselorKeith.com/application-interview-booking

Once you click the above link and the new tab/window
is open you may click 'OK' then 'DONE' below.

Return to the newly opened tab/window.
Here you will schedule a 1-on-1 phone call with Keith Dorscht
to review your application and discuss how he can help you.