You can always press Enter⏎ to continue
Woman's Potential in Relationships - INTAKE
9
Questions
START
1
Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
Email
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
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.
Previous
Next
Submit
Press
Enter
4
On a scale of 1-5, with 1 being "NOT important at all" and 5 being "Extremely important", how would you rate how important each of the following is when it comes to marriage?
*
This field is required.
1 - NOT important at all
2
3
4
5 - EXTREMELY important
Partnership
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Understanding
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Loyalty
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Trust
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Support (for one another)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Affection
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Romance
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Compromise
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Having fun
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Partnership
Understanding
Loyalty
Trust
Support (for one another)
Affection
Romance
Compromise
Having fun
1 - NOT important at all
Row 0, Column 0
2
Row 0, Column 1
3
Row 0, Column 2
4
Row 0, Column 3
5 - EXTREMELY important
Row 0, Column 4
1 - NOT important at all
Row 1, Column 0
2
Row 1, Column 1
3
Row 1, Column 2
4
Row 1, Column 3
5 - EXTREMELY important
Row 1, Column 4
1 - NOT important at all
Row 2, Column 0
2
Row 2, Column 1
3
Row 2, Column 2
4
Row 2, Column 3
5 - EXTREMELY important
Row 2, Column 4
1 - NOT important at all
Row 3, Column 0
2
Row 3, Column 1
3
Row 3, Column 2
4
Row 3, Column 3
5 - EXTREMELY important
Row 3, Column 4
1 - NOT important at all
Row 4, Column 0
2
Row 4, Column 1
3
Row 4, Column 2
4
Row 4, Column 3
5 - EXTREMELY important
Row 4, Column 4
1 - NOT important at all
Row 5, Column 0
2
Row 5, Column 1
3
Row 5, Column 2
4
Row 5, Column 3
5 - EXTREMELY important
Row 5, Column 4
1 - NOT important at all
Row 6, Column 0
2
Row 6, Column 1
3
Row 6, Column 2
4
Row 6, Column 3
5 - EXTREMELY important
Row 6, Column 4
1 - NOT important at all
Row 7, Column 0
2
Row 7, Column 1
3
Row 7, Column 2
4
Row 7, Column 3
5 - EXTREMELY important
Row 7, Column 4
1 - NOT important at all
Row 8, Column 0
2
Row 8, Column 1
3
Row 8, Column 2
4
Row 8, Column 3
5 - EXTREMELY important
Row 8, Column 4
1
of 9
Previous
Next
Submit
Press
Enter
5
How much do you feel that this statement applies to you: “My husband and I are equals – our roles and strengths may be different, but equal.”
*
This field is required.
1
2
3
4
5
Does not apply to us at all
Strongly applies to us
Previous
Next
Submit
Press
Enter
6
Describe how you and your husband handle work, home, and financial responsibilities (i.e. Do you just divide and conquer everything exactly equally? Do you sit down and talk about how to approach each thing? Do you have established roles? Etc.) Describe your dynamics.
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
7
Does your husband ever ask you for help?
*
This field is required.
Yes – I make sure he knows he can always come to me for anything and everything.
Sometimes – but I’m not sure how he feels about it.
Not really – between us, I’m probably the one who usually needs his help.
Previous
Next
Submit
Press
Enter
8
If you met a good fairy, who offered to grant you one wish pertaining to your marriage, what would that wish be?
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
9
Is there anything else you feel is important for the therapist to know before we start the chat?
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
9
See All
Go Back
Submit