MODULE 2 INTAKE SURVEY

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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Mobile Phone number* This field is required.Please make sure to use hte SAME NUMBER that you used to sign up for Telegram. If you're not sure, please go to the app and find out. This is the number we are going to use for sending you the invite link. YOU WILL NOT RECEIVE OTHER CALLS OR TEXTS ON THIS NUMBER
Please enter a valid phone number.
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Please rate your current situaion in your relationship using the questions below. If you feel that any particular situaion does not apply to you, give it a rating of one, as opposed to trying to skip it.
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How close do you feel with your partner?* This field is required.1- distant 5- we have a strong emotional connection
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5
NOT AT ALL
EXTREMELY
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How intimate a relationship do you have, or did you have, with this person?* This field is required.
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5
NOT AT ALL
EXTREMELY
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How much of an authority figure is this person for you?* This field is required.
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5
NOT AT ALL
EXTREMELY
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How enjoyable is or was the relationship at its best?* This field is required.
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5
NOT AT ALL
EXTREMELY
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How difficult is or was the relationship at its worst?* This field is required.
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NOT AT ALL
EXTREMELY
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How would you rate the stress level of this relationship? Is it stressful?* This field is required.
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NOT AT ALL
EXTREMELY
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How sure are you about understanding what is going on in your relationship? How confused are you now?* This field is required.
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NOT AT ALL
EXTREMELY
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How much do you trust the sincerity of your partner in this relationship?* This field is required.
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NOT AT ALL
EXTREMELY
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How much are your problems affecting your kids?* This field is required.
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5
NOT AT ALL
EXTREMELY
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To what extent are other people (friends, in-laws, etc.) influencing your relationship?* This field is required.
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5
NOT AT ALL
EXTREMELY
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Do you wish you had more closeness with your partner?* This field is required.
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NOT AT ALL
EXTREMELY
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How overdue are you for a good heart-to-heart conversation, in your opinion?* This field is required.
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NOT AT ALL
EXTREMELY
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Do you wish for more understanding between you two?* This field is required.
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NOT AT ALL
EXTREMELY
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Do you wish you had more control over your partner?* This field is required.
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NOT AT ALL
EXTREMELY
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Do you wish you had more control over what is going on in your relationship?* This field is required.
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NOT AT ALL
EXTREMELY
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Do you feel you’re the one who solves most of the problems in your relationship?* This field is required.
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NOT AT ALL
EXTREMELY
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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
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Have you taken Relationship X - Module 1?* This field is required.
Yes
No
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What is your sense of commitment for staying in a relationship in general?* 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
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Where are you at in terms of your commitment in THIS relationship?* This field is required.
I would like to save this relationship, but my partner is seeking to break-up with me
I would like to save this relationship, but I’m not sure if I can handle it much longer
I would like to leave this relationship, but I feel trapped
I am not sure where I’m at with this, and need help figuring out the answer to this question
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Please rate the following statements on the scale of 1 to 5, with 1 being NEVER TRUE FOR ME and 5 being DEFINITELY TRUE FOR ME
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I do something different to surprise my partner such as buy flowers, leave a love note, or buy a present for no special event at least once a week.* This field is required.
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5
NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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It is NOT ok for one partner to go away for a weekend by themselves to think and be alone.* This field is required.
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5
NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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One should always consult with their partner before making even small financial decisions.* This field is required.
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NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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If I am under more stress than usual, my partner will usually do extra things for me.* This field is required.
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5
NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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A long term commitment (would) cause(s) me to feel trapped.* This field is required.
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5
NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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I have told my partner almost everything about myself.* This field is required.
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5
NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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My partner has close friends of his/her same sex with whom he/she has frequent social contact outside work.* This field is required.
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5
NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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If my partner makes a decision concerning his/her own personal matters, and I do not agree with it, I almost always am supportive and encouraging to my partner.* This field is required.
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5
NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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It is ok for one partner to go out to lunch alone with an attractive friend of the opposite sex.* This field is required.
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NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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I am extremely attracted to my partner sexually* This field is required.
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NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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My partner and I both enjoy playfully teasing each other several times per week.* This field is required.
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NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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The (marriage) relationship is more important than the happiness of one partners.* This field is required.
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NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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A couple should almost never argue or disagree if they are to have a truly happyrelationship.* This field is required.
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NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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I would end my relationship if staying in it meant that I could not grow as aperson.* This field is required.
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5
NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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My partner and I strongly agree on most long term goals.* This field is required.
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NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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When my partner and I have a discussion or argument, we almost always stay on one issue at a time.* This field is required.
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NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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Overall, my partner and I are equal in how much influence we have in decisions* This field is required.
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NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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When I discuss an important issue with my partner, I go ahead and tell my partner almost exactly what I am thinking and feeling--even though it might upset him/her. My partner does the same* This field is required.
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NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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There are certain tasks that are MORE the man's responsibility, such as providing economic support, taking care of the car, etc* This field is required.
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NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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There are certain tasks that are MORE the woman's responsibility, such as cleaning house, fixing meals, etc.* This field is required.
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5
NEVERTRUE FOR ME
DEFINITELY TRUE FOR ME
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Please briefly describe the problem in your relationship which you feel is most vital right now* This field is required.
Huge
Large
Normal
Small
Ok
Ok
47
If a magician appeared and asked you to make one wish regarding your relationship, which he would then make come true, what would be your request?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
48
What is your main expectation of the coaching session? IN other words, what problem are you trying to solve or what goal to accomplish as the outcome of it?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: