Breakthrough To Love Session Questionnaire

First Name:*

Last Name:*

Phone:*

Email:*

WHERE ARE YOU AT RIGHT NOW IN RELATIONSHIP?*
 Single Dating -- not yet exclusive Dating -- committed Other

HOW SATISFIED ARE YOU WITH YOUR LOVE LIFE?*
 What Love Life? Not Satisfied Somewhat Satisfied Very Satisfied Love of my Life

WHAT IS YOUR BIGGEST CHALLENGE IN YOUR LOVE LIFE/DATING LIFE RIGHT NOW?*

WHAT HAVE YOU TRIED IN THE PAST TO IMPROVE YOUR LOVE LIFE/DATING LIFE?*

WHAT ARE YOU LOOKING FOR IN YOUR IDEAL RELATIONSHIP?*

WHEN DO YOU WANT TO BE IN AN EXTRAORDINARY, EPIC, LOVING PARTNERSHIP? *
 3 months from now 6 months from now 1 year from now

ON A SCALE OF 1 TO 10, WITH 10 BEING 100% COMMITTED, HOW COMMITTED ARE YOU TO FINDING LOVE?*

DO YOU HAVE OR WANT TO HAVE BABIES? *
 Yes, I have kids I'm actively trying to have a baby now or soon I would love to have a baby in the next 5 years or so No

PLEASE COMMIT TO YOUR APPOINTMENT BY TYPING THIS SENTENCE IN THE BOX BELOW: "YES, I PROMISE I WILL ANSWER THE PHONE FOR MY BREAKTHROUGH SESSION AT MY BOOKED APPOINTMENT TIME :-)*

ON A SCALE OF 0 TO 10, HOW EXCITED ARE YOU TO TALK TO MIRA AND TO FINALLY FIND THE MAN OF YOUR DREAMS AND HAVE LASTING LOVE? *

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