Full Name [of Applicant/Partner One] *

Age (DOB) *

Age (DOB) of Partner *

Email *

Phone *

City *

State *

My relationship status is: *

How long have you been in/were you in this relationship? *

If selected, my parter WILL/WILL NOT be willing to appear on the show: *

Partner Two, Full Name *

Upload your love story! *

Love Story (cont.) - Use this area to provide any additional details you weren't able to capture in the video.

What happened? Share 2-5 of the most impactful incidents you've had to navigate as a couple, and what has you asking whether your partner is "The One": *

Please share any personal trauma or hardship that you feel has had an impact on your current relationship or a previous relationship. *

Have you had any previous therapy, counseling or coaching--either individually or as a couple. If yes, how do you feel about the guidance you received? *

Gender: Applicant/Partner One *

Gender: Partner Two *

Photo Upload: Head/Face Shots of Couple *

Photo Upload(s): Full Body Shots of Couple *

Social Media + Links [for Applicant/Partner One] *

Social Media + Links [for Partner Two] *

Race / Ethnicity / National Identity [of Applicant/Partner One] *

Additional Details [for Applicant/Partner One] *

Race / Ethnicity / National Identity [of Partner Two] *

Additional Details [for Partner Two]

NAME, IMAGE and LIKENESS *

LIABILITY WAIVER
*

Electronic Signature *