Consent *

I understand that the information that I provide to Motivating Marriages Psychology via this online application form remains confidential and will not be shared with any third parties

I understand that a deposit of $950 is due to secure your booking. This consists of payment for your Relationship Wellbeing Assessment and the first of three payments for your Marathon Therapy.

I understand that payment for Marathon Therapy ($4500) is due in full 3 weeks before the date of your Marathon Therapy.

Partner 1 Name *

First Name

Last Name

Mobile

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Partner 2 Name

First Name

Last Name

Mobile

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