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Birth Information
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Questionnaire
How did you hear about me and my work? *
Have you worked with any of my materials? Book, reports, calendar, programs, readings, previous workshop? LMK!!) *
Why are you interested in the workshop? *
What is your relationship status? 1. not even dating 2. dating but no one special 3. seeing someone but unsure 4. living with someone but unsure/or sure and it’s not “going the distance” 5. married but want to be closer 6. married but separated 7. recently broken-hearted *
How many “serious” relationships have you had (when you were serious, exclusive, and in love – even if briefly) *
Have you been married? How many times? Briefly tell me how long you were married and why you divorced, and who initiated the divorce? *
What do you think has been your biggest challenge in having the relationship you want? Or in being happy in one? *
What do you think is your greatest strength or gift that you bring to the men in your life? *
On a scale of 1 – 10, how do you rank your romantic relationships? Why? *
On a scale of 1 – 10, how would you rank your parents’ relationship when you were living with them? Why? *
On a scale of 1 – 10, how willing are you to do whatever it takes to have the relationship you want? *
On a scale of 1 – 10, how hopeful are you that your romantic dreams can come true? Why or why not? *
What other resources have you turned to for support with overcoming your single status? 1. other coaches (who?) 2. books 3. other workshops 4. therapy/support groups 5. nothing – you keep busy with other things 6. just talking to friends and family - What’s worked/helped? *
Do you play well with other women? If not, you’ll have to change that if you want to come…) *
What is your romantic goal for your life? (To be married for fifty years, to have three boyfriends who all worship you and don’t compete, to have a life partner whether you marry or not, to stay single forever…) *
Thanks so much for taking the time to fill this out. I’ll be in touch very soon!
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