Marriage Help | Marriage Mediation

Marriage Mediation Request

Client Information

First Name

Last Name

Phone Number

Client Email

Spousal Information

First Name

Last Name

Phone Number

Spouse Email

Address Line 1

Address Line 2

City

Country

State

Provinces

State/Province

Postal Code

Years Married

Are you currently separated?

Husband's Occupation

Wife's Occupation

Describe why you believe your marriage is struggling

Has there been any form of infidelity, addiction or abuse?

By whom did it occur and when did you find out?

Have you or your spouse received any counseling related to it?

Have you previously worked with an XO Marriage Mediator?

Mediator Name

How Did You Hear About XO Marriage Mediation?

Who referred you?

Let us know how!