Name*

Email*

Phone*

Text Okay?* YesNo

Zip Code*

How long are you married?* Less than 1 year1 to 5 years5 to 10 years10+ years

Are you currently separated?* YesNo

Is your spouse aware you are considering divorce / legal separation?* YesNoNot Sure

Do you have minor children together?* YesNo

Do you own a home together?* YesNo

Is your spouse employed?* YesNo

Are you employed?* YesNo

Please share anything else you would like us to know.