Name:

Email:

Please briefly tell me a little bit about yourself:

Briefly tell me about your romantic relationship history:

What do you feel is slowing you, down, standing the way or stopping you from having the relationship of your dreams?:

Do you have any other commitments that would keep you from being 100% successful in this program? This could be a job, family, children, health, your ex, etc:

What is the reason you are seeking support in your love life at this time?:

What do you most hope to get from our conversation together?:

On a scale of 1 to 10 with 10 being high, what numerical value would you give in terms of how important it is for you to address this area of your life right now? (i.e. 1=low priority and10=extremely high priority).:

Are you prepared to financially invest in yourself to move forward toward having the relationship of your dreams?:

If selected, describe why YOU are a good candidate for Michelle's Love After 60 program:

Please enter your phone number: