interest in private coaching
Thank you for your interest in becoming a coaching client!

Kindly respond to the following questions and Savvy will be in touch with the application/intake form.
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Email *
Full Name *
Cell # *
City, State, Zipcode *
How did you find The Modern Mr. and Mrs. LLC (Google search, referral, Facebook, Instagram, etc.)? *
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How long have you known about The Modern Mr. and Mrs. LLC? *
Required
Please check off your relationship status below *
Do you (and/or your partner) have any kids? *
If you have kids, please list the following for each child 1. Gender 2. Age 3. Whether the child has unique needs that puts strain or challenges the relationship (yes/no answer is fine) *
Please check off which describes your relationship history/what is currently occuring *
When was Discovery/Disclosure Day (if you have porn/sex addiction or cheating in your relationship)
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If you are the addict, when was the last time you engaged in masturbation, pornography, pornography substitutes, or real life interaction?
Have you gotten any type of help, if so please check them off *
Required
If you marked any of the above, please list with whom you've gotten help with, when, and the duration of your time working together *
Have you watched any of Savvy's videos that are on her site/social pages? *
What led to you filling out this application to become a client at The Modern Mr. and Mrs. versus other options? *
What about right now made it the right time to get coaching? *
What are the biggest issues you are struggling with right now? *
What are your top 5 goals you'd like to achieve in coaching? *
What have you tried in the past that was not effective or didn't work to achieve your goals? *
Does anyone in the relationship have any neurodiversity that impacts the relationship? (i.e. autism, adhd, etc.) *
If you or your partner have any mental health struggles, you acknowledge that you have a therapist to address those mental health issues in tandem with coaching services or have completed therapy to address those challenges *
Which program/service are you interested in and would like more information on? (Check all that apply) *
Required
If you're signing up for live coaching sessions (audio or video), please select your top 2-3 days with availability for coaching sessions *
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If you're signing up for live coaching sessions (audio or video), please select your top 2-3 time slots of availability for coaching sessions *
Required
I acknowledge that I'm ready to invest a minimum of $220/month. *
Please share an ETA of when you would like to begin coaching should we be a good fit to work together *
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Do you have any questions that I can answer for you right now? *
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