Dialog Facilitator Intake

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone * 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
What is the nature of your relationship?* This field is required.
General
Strained
Abusive (emotionally or physically)
New
5
What is the main purpose of this communications?* This field is required.
To straighten things out
To clarify how I/he/we feel
I want to tell him something, but I don’t know how to put it so that he understands
I want to tell him something, but I don’t know how to put it so that he understands and does not get offended or takes it wrongly
I want to tell him something, but I don’t know how to put it so that he doesn’t get mad and/or this makes things worse
To tell him he is an ass – but I just don’t have time or care to fight right now
To ask for a favor/help/cooperation
6
Please describe the back ground of your relationship that you feel is important for me to know* This field is required.
Huge
Large
Normal
Small
Ok
Ok
7
What is your question/statement/request?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: