LCA Survey Form

1

Relationship Status?

Single

In a relationship

2

Please Say More . . .?* This field is required.

Single - Not Dating

Single - Dating

Single - Non-monogamous

3

Please Say More . . .?* This field is required.

I'm Married

I'm in a Committed Relationship - Living Together

I'm in a Committed Relationship - Living Apart

It's Complicated

I'm in Open Relationship/s

4

Are you seeking resources and tools to improve your relationships?* This field is required.

I would like to work with a coach who specializes in non-monogamy.

I am seeking communication skills and interpersonal skills to improve my relationships.

I am looking to work on self acceptance, maybe even self-love and interdependence.

I am looking for support to relate more consciously with emotional literacy and transparency.

I'm experienced ;), and I am interested in learning to coach others.

5

How long since your last long term relationship?* This field is required.

less than 6 months

6 months - 1 year

1 year - 5 years

5 years and up

6

The best part of being in relationship is . . .* This field is required.

7

The worst part of being in relationship is . . .* This field is required.

8

Relationships would be great if only . . .* This field is required.

9

What I most want in relationship is . . .* This field is required.

10

How important is having a relationship?* This field is required.

My #1 priority - actively looking and dating

Important, casually looking, but not dating yet

Someday soon, still healing from past experiences, etc.

Very happy being single right now

Not looking - relationships are too much work

Never again - relationships suck

11

What would be most helpful for you?* This field is required.Select as many as you like.

Learn new relationship skills so my next relationship is my best relationship

Figure out what went wrong in the last relationship so it doesn't happen again

Improve my personal wellbeing and all of my relationships with others

Find the right community

12

How committed are you to building Remarkable Relationships?* This field is required.

Priority - this is very significant for me

Committed - want to learn what I can do differently

Interested - but still healing from my last relationship

Interested - but I have a busy life

Not interested in dating at this time

13

Are you interested in any of these tools to improve your relationships?* This field is required.

I would like to work with a coach who specializes in non-monogamy.

I am seeking communication skills and interpersonal skills to improve my relationships.

I am looking to work on self acceptance, maybe even self-love and interdependence.

I am looking for support to relate more consciously with emotional literacy and transparency.

I'm experienced ;), and I am interested in learning to coach others.

14

How long have you been in relationship?* This field is required.

less than 1 year

1 year - 5 years

5 years - 10 years

10 years - 20 years

More than 20 years

15

The best part of being in a relationship is. . . * This field is required.

16

The worst part of being in a relationship is . . .* This field is required.

17

My relationship would be great if only . . .* This field is required.

18

What I most want in relationship is . . .* This field is required.

19

Are you here today because of...* This field is required.

Problem - you want to solve a current problem in your relationship

Prevention - you would like to prevent a problem you see coming

Possibility - you want to make your relationship remarkable

20

How is your relationship now? Which best describes your current situation?* This field is required.

a) Great - It's a Remarkable Relationship with that Special Spark.

b) Good - It's ok, somewhat satisfying, we love each other but know it could be even better.

c) Stuck - We are stuck in a relationship rut and nothing we have tried has helped so far.

d) Conflict - Lots of Trauma, stress & triggers, issues keep coming up & don't get resolved.

e) Crisis - We are struggling to get along. Wondering should I stay or should I go?

21

How pressing is your situation?* This field is required.

a) Urgent - will destroy our relationship if not changed

b) Pressing - could destroy our relationship if not addressed soon

c) Important - would enjoy handling this issue in the near future

d) Interested - but don't have the time or energy now

22

How can we support you?* This field is required.Chose as many as you like.

a) I would like to connect with a Love Coach for INDIVIDUAL SUPPORT or for COUPLE'S COACHING.

b) I would like to talk to a Love Coach about the courses on LCA offers on improving Communication Skills, Emotional Intelligence, and Better Relationships

c) I would like to speak to a Love Coach who can instruct me in Light Touch practice...

d) I am interested in talking to someone about becoming a Love Coach

23

How can we support you...?* This field is required.Chose as many as you like.

a) I would like to connect with a Love Coach for individual or for couple's counseling. (best option if your relationship is in crisis or conflict...)

b) I would like to talk to a Love Coach about the courses on LCA offers on improving Communication Skills, Emotional Intelligence, and Deeper Relationships

c) I would like to speak to a Love coach who can instruct me in Light Touch practice...

24

Do You Have a Preferred Gender For The Coach Who Contacts You...

Best for my situation

Male

Female

Other

25

What's Your Name?* This field is required.

26

What's your email?* This field is required.

example@example.com

27

Best Phone Number for the Love Coach to contact you and set up your 15 minute complimentary discovery session?* This field is required.

Area Code

Phone Number