The Giving Goddess

1
Date
Date
Year
Month
Day
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Name* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Area Code
Phone Number
5
Relationship Status* This field is required.
Single (Not Dating Anyone)
Married
Separated
Dating Someone
6
Do You Experience Any of the Following?* This field is required.Review each of the symptoms below and identify any that you currently suffer from?
Anxiety
People Pleaser
Depression
Perfectionist
Self-Critical
Feel Taken Advantage of
Apologizes for No Reason
Overly Compassionate
Provides Unsolicited Advice
Fearful of Abandonment
Fearful of Rejection
Fearful of Judgment
Compare Yourself to Others
Need Others to Validate Worth
Low-Self Esteem
Lack-Self Worth
Indecisive at Times
Take On Others Responsibilities
Low Energy
7
As a Child Did You Experience Any of the Following?* This field is required.
Abuse of Any Kind
Poverty or Financial Lack
Neglect
Emotionally Distant Caregiver
Learned Helplessness
Judged by Family
Fear-Based Upbringing
Favoritism of Sibling
Abandonment (death of parent or adoption)
Emotional Manipulation
Parent Living Vicariously Through You
Chaotic Family Dynamic
Sick Parent or Sibling
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What About Your Relationship Are You Unhappy About?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
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How Much of Problem Do You Feel You Have in Your Relationship?* This field is required.
No Problem At All
Somewhat of a Problem
A Major Problem
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Is the Relationship Confusing or Painful?* This field is required.
Yes
No
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Are You Comfortable Expressing Yourself to Your Partner?* This field is required.
Yes
No
12
Is the Relationship Mutually Beneficial?* This field is required.
No
Yes
13
Are You Expected to Sacrifice When Your Partner Doesn't Compromise?* This field is required.
Yes
No
14
What Have You Had to Give Up On As A Result of Your Relationship? (e.g. think of dreams you have repressed, missed opportunities etc..) * This field is required.
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Right Now I ..* This field is required.
Have financial resources to invest in healing myself
Have access to financial resources to invest in healing myself
Don't have any financial resources to invest in healing myself
16
Schedule Your Relationship Checkup
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I will call you at the scheduled time. Do you promise to answer the phone? Type 'YES' below. * This field is required.
Should be Empty: