Affair Recovery Intake Form

Affair Recovery Client Intake Form

Name(Required)

First Last

Email(Required)

Phone

How did you hear about Lora?(Required)

What are your top goals for yourself over the next 1-3 years?(Required)

What do you crave to create for yourself on the other side of infidelity and betrayal?(Required)

How do you want to feel, show up, and be as you go forward in life?(Required)

What have you tried before (if anything) and why didn’t it work?(Required)

What are you struggling the most with right now?(Required)

What does “healing from betrayal” mean to you?(Required)

Why do you think Lora could be the right coach for you?(Required)

What is the current status of your relationship?

Are you interested in reconciling, divorcing, or are not sure?

If you decided to work with Lora, are you able to make a six month commitment?(Required)

Yes

Not right now

Select Payment Option(Required)

6 Monthly Payments -$497.00

Paid In Full- $2,797.00

Coupon

Total

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

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Credit Card

Card Details

Cardholder Name

This field is for validation purposes and should be left unchanged.