Contact information

First name

Last name

Email

Instagram Handle

Phone Number

Instagram Handle

What’s your #1 challenge with dating right now?

How long have you been experiencing this issue?

Less than 3 months

3–12 months

Over a year

My whole life

What have you tried so far on your own that didn’t work?

What result do you want to achieve in the next 90 days?

Qualification

How committed are you fixing this?

I’m fully committed — I’ll do whatever it takes.

I’m committed but may need some accountability

I’m interested, but not ready to go all-in yet.

Are you financially able & willing to invest in coaching if it’s a good fit?

Yes, I’m ready to invest in myself

Yes, but I need a payment plan

Not yet, but I’m interested in learning more

No

Why do you want to be coached by Jeremy specifically?

When can you start?

ASAP

This month

Next month

Not sure yet