Working with Terry - Application

Application Type

Are you applying as an individual or as a couple?

I am applying as:

An individual

A couple

Your Information

Full Name

Email Address

Phone Number

Your Timezone

Availability

I confirm availability for Tuesday 17 March at 12pm ET

I understand I may be asked to attend a later session

Couple Information

Please provide details for both partners.

Partner 1 Full Name

Partner 2 Full Name

Partner 1 Email

Partner 2 Email

Partner 1 Phone

Partner 2 Phone

Your Timezone

Availability

We confirm availability for Tuesday 17 March at 12pm ET

We understand we may be asked to attend a later session

Screening Questions

Please answer honestly. Your responses are confidential and help us determine if this format is a good fit.

Are you currently single or in a relationship?

Single

In a Relationship

Is there an active affair in your relationship?

Yes

Is there any physical violence in your relationship?

Yes

Is there an ongoing addiction (substance or behavioral) affecting you or your relationship?

Yes

Have you worked with an RLT-trained therapist before?

Yes

Are you comfortable being recorded for educational purposes?

Yes

Is there an active affair in your relationship?

Yes

Is there any physical violence in your relationship?

Yes

Is there an ongoing addiction (substance or behavioral) affecting either of you or your relationship?

Yes

Have you worked with an RLT-trained therapist before?

Yes

Are you both comfortable being recorded for educational purposes?

Yes

About Recording
Sessions with Terry are recorded for educational purposes as part of the Living Love program. Recordings may be shared with Living Love participants and used in future RLI educational materials. By proceeding, you acknowledge your understanding of this.

Video Submission

Please record a short video (3-5 minutes) introducing yourself and describing the issue you'd like to work on with Terry. Upload to Loom or Google Drive and paste the link below.

In your video, please cover:

Introduce yourself (and your partner, if applying as a couple)
Briefly describe the issue you want to bring to the session
What outcome or shift are you hoping for?

Video Link

Consent

I consent to my session with Terry Real being recorded and used for educational purposes within the Living Love program and future RLI materials.

I confirm that all participants in this application have given their informed consent to participate and be recorded.