Name
*
First Name
Last Name
I know who I am.
Disagree
Agree
I know what I want.
Disagree
Agree
I know how to ask for what I want.
Disagree
Agree
I know what is important to me.
Disagree
Agree
I know how to set boundaries.
Disagree
Agree
I'm able to say no to my wife.
Disagree
Agree
I have many close male friends.
Disagree
Agree
I have hobbies and activities outside my home.
Disagree
Agree
I am comfortable spending time with myself.
Disagree
Agree
I take my wife's comments personally.
Disagree
Agree
I defend, justify, or explain my actions to others.
Disagree
Agree
I try to not make any mistakes.
Disagree
Agree
I try to have a problem free life.
Disagree
Agree
I try hard to make other people happy.
Disagree
Agree
I feel like I am doing everything I'm supposed to be doing.
Disagree
Agree
I don't feel like others are doing what they are supposed to be doing.
Disagree
Agree
I feel undesired in my marriage.
Disagree
Agree
I feel unwanted in my marriage.
Disagree
Agree
I feel unloved in my marriage.
Disagree
Agree
I feel alone in my marriage.
Disagree
Agree
I feel like an ATM in my marriage.
Disagree
Agree
I feel like a security guard in my marriage.
Disagree
Agree
I feel like a maintenance man in my marriage.
Disagree
Agree
I feel like an Uber Driver in my marriage.
Disagree
Agree
I feel unhappy in my marriage.
Disagree
Agree
I daydream about leaving my wife.
Disagree
Agree
I daydream about running away and starting a new life.
Disagree
Agree
I want connection with my wife.
Disagree
Agree
I want more affection from my wife.
Disagree
Agree
I want my wife to want me.
Disagree
Agree
I want to experience positive change in my marriage.
Disagree
Agree
I am willing to work for what I want.
Disagree
Agree
I am willing to invest time, effort, and money on becoming the man I am proud of being.
Disagree
Agree
Is there anything else you want to share?
Phone
(###)
###
####
Best time to call?
Email
*
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