Relationship X: Initial Intake

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number* This field is required.(The phone number will be used to assign you to a Telegram group. You will not be receiving any calls. Please use the same phone number that you have used to register on Telegram. If you’re not sure, please open the app and double check. This is very important – otherwise, I will be able to add you to the group)

Please enter a valid phone number.

4

How familiar are you with Holistic Psychology?* This field is required.

Very familiar. Use Holistic Life Coaching before and had great results

I used Holistic Psychology help before, but it didn’t work for me

Heard about it, and am very curious

Totally new to the approach

5

What is your level of need for help in this relationship?* This field is required.

Urgent. Something needs to be done now

Moderate: I feel things need to change soon, or it won’t be pretty

No rush: just trying to make the situation better

6

What is your sense of commitment for staying in a relationship?* This field is required.

I believe that relationships must be saved no matter what – it is the right thing to do

I feel that it is always best to save a relationship, but sometimes it may not be possible

It depends on the nature of a relationship: there are good ones and bad ones

It’s a matter of personal choice. Ethical considerations for staying or leaving are overrated

I struggle with the very concept of a monogamous relationship – who you are with at any given time should not be an issue

7

What is the nature of your relationship?* This field is required.

Husband and wife

Boyfriend – girlfriend

Initial interest

Not currently in a relationship

8

What is your main goal -- in terms of change or achievement – that you’re looking to check off your list by going through this session?* This field is required.

9

If you met a good fairly, who offered to grant you one wish related to your relationship life, what would that wish be?* This field is required.

10

If you met a prophet (God, Seer, World famous tarot reader, etc.) who offered to answer one question regarding your relationship, what question would you ask him?* This field is required.

11

What is your general goal (check all that apply)?* This field is required.

To save my current relationship

To improve the relationship by increasing understanding and love between us

To improve the relationship by reducing fights and misunderstandings

To improve communication between us

To leave a toxic relationship

To make a decision whether to stay or leave

To sort through my previous relationship mistakes and prepare for success in my new relationship

To heal after a break-up

To understand the dynamics of this relationship so that I can take better decisions in general

12

Would you say that there is a significant amount of stress in your current relationship situation?* This field is required.

Yes

No

Define “significant”

13

Do you love this person?* This field is required.

Yes

I used to. Not sure any more

I used to. But no

I never loved him

14

Do you feel a sense of chaos and confusion in your relationship that you want to solve or simply have specific questions that you need answered?* This field is required.

Need to sort things out

Have specific questions

15

Please list 3 questions that you're seeking to resolve* This field is required.

16

What is the behavior that most bothers you about your partner?* This field is required.

17

What is it that you most want them to learn to be better at?* This field is required.

18

What have you succeeded in improving in your relationship in the past?* This field is required.

19

Is your partner addicted to anything or breaking the law in any way that you are aware of.* This field is required.

20

What are your own weaknesses? Do you have addictions?* This field is required.

21

How do you ask for what you need at the moment? Is it effective?* This field is required.

22

Do you and your partner have an active sex life? Are you satisfied sexually by your partner? Do you know if you satisfy them sexually? Do you know if they are faking orgasm or not? Do you ever climax together?* This field is required.

23

Is there any grudges your partner holds against you that you are aware of? Are they angry about something that they may or may not let you know about?* This field is required.

24

Who earns the money in your relationship? Does your partner have a job? Do you? How is the money shared and are there conditions on that?* This field is required.

25

Are there other people in your life you feel put down by? (briefly)* This field is required.

26

How much time do you spend together?* This field is required.

27

Have you even given your partner a nice picture of you (your face)? What was his reaction?* This field is required.

28

Do you or your partner suffer from mood swings, anxiety or depression?* This field is required.

29

Do you each get sunshine (outdoors) and exercise regularly?* This field is required.

30

Do you get enough sleep - in a dark room where you are undisturbed?* This field is required.

31

Is there anything else I should know about that may be causing these problems that hasn’t been listed here?* This field is required.

32

Please give a brief idea of the back story regarding your current problems* This field is required.