Regenerate Your Marriage Private Intensive

Questionnaire

A private, in-depth experience for couples who are ready to heal, rebuild, and begin again.

Thank you for your interest in the Regenerate Your Marriage Private Intensive.

This 3-day, in-person experience is designed for couples who are truly ready to do the work of healing, rebuilding trust, and restoring connection. Your honest answers will help us determine whether this intensive is the right next step for your marriage and ensure we can serve you with the highest level of support.

Please complete this questionnaire together. Each partner may answer individually where prompted.

Basic Information

Partner A Name *

Partner A E-Mail *

Partner A Phone Number

Partner B Name *

Partner B E-Mail *

Partner B Phone Number

How long have you been married?

Do you have children together or from previous relationships?

If yes, please share ages:

Your Marriage Today

What led you to seek a Private Intensive at this time?

What are the top three challenges your marriage is facing right now?

Have you experienced any of the following? (Select all that apply)

Other:

On a scale of 1–10, how hopeful are you that your marriage can heal? (Each partner should provide an answer.)

On a scale of 1–10, how committed are you to saving your marriage, even if the road is difficult and emotional? (Each partner should provide an answer.)

Your Readiness for the Work

Are you both willing to look honestly at your own patterns, choices, and contributions to the challenges in your marriage? (Yes, No, or Unsure; each partner should provide an answer)

Are you willing to try new tools and practice new behaviors that may feel uncomfortable at first? (Yes or No; each partner should provide an answer)

When conflict happens, how do you each typically respond? (Each partner should provide an answer.)

What previous counseling or coaching have you done, individually or as a couple? (Each partner should provide an answer.)

What worked and what didn’t work in those experiences? (Each partner should provide an answer.)

Trust, Forgiveness & Emotional Capacity

What wounds are you bringing into this intensive that you believe need to be addressed? (Each partner should provide an answer.)

Are you willing to forgive—and be forgiven—if healing calls for it? (Yes, Not Yet, or Unsure; each partner should provide an answer)

What would emotional safety look like for you during this intensive? (Each partner should provide an answer.)

Goals for Your Marriage

What do you hope your marriage will look like six months from now? (Each partner should provide an answer.)

What would “success” in this intensive look like for you? (Answer this question together.)

What strengths do you believe your marriage still has? (Answer this question together.)

Practical & Financial Commitment

This intensive requires both emotional and financial investment. Are you both prepared to commit to the full experience (3 days in our home + 4–6 months of follow-up coaching)? (Yes, No, or Need Clarity; each partner should provide an answer)

Are you prepared to make the financial investment of $15,000 for this level of support and transformation? (Yes or No; each partner should provide an answer)

Are there any financial concerns or questions you would like us to address before scheduling? (Answer this question together.)

Logistics

Do you have any dietary needs, allergies, or physical limitations we should be aware of during your stay? (Answer this question together.)

Are there any personal boundaries, triggers, or sensitivities we should know to ensure your safety and comfort? (Each partner should provide an answer.)

Final Reflections

If you could each speak from your heart for a moment… what is one thing you want your spouse to know as you consider this next step? (Each partner should provide an answer.)

Is there anything else you want us to know before we follow up? (Answer this question together.)