Activate Your Personal Coaching Subscription (MTM PP)

Please fill out this form to activate your personal marriage coaching subscription and begin working with Brad.

If you run into problems or need further assistance, please email [email protected].

PayPal billing email address: *

***IMPORTANT*** Please enter the email address associated with your PayPal account (or the email address that you provided on the PayPal order form when registering). I will use this to verify your subscription.
Preferred contact email: *

Please enter the email address you would like to use for coaching correspondence (this does not have to be the same address used on the PayPal registration form). I will reply to you at this email address.
Your Name * First Last
Please enter your name. This will remain strictly confidential.
Your location (ie. city/country): *

Where do you currently live? You may be as specific or vague as you wish.
Your gender: *

Your gender: I am male. I am female.
Your Age:

Please provide your age (optional, but helpful).
Your Spouse's Age:

Please provide your spouse's age (optional, but helpful).
Your Spouse's Name: *

Please enter your spouse's name (you may use a fake name if you wish):
How long have you been married? *
Do you have children with your spouse? *
Do you and your spouse still live in the same household? *

Do you and your spouse still live in the same household? Yes, we live together. No, we are separated.
Please briefly describe your situation: *
Maximum of 300 words allowed. Currently Entered: 0 words.
Enter any comments or important information regarding your marital problems, points of contention, etc. Please limit your comments to 300 words.
Specific Question #1:

Please ask a specific question you would like me to answer:
Specific Question #2:

Please ask a specific question you would like me to answer:
Specific Question #3:

Please ask a specific question you would like me to answer: