Leaving a Relationship -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 much do you feel that this statement applies to you: “I am exactly who I should be at this moment.”

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2
3
4
5

Does not apply to me at all

Strongly applies to me

5

If you had to choose one thing to change about your life situation IN GENERAL, what would it be?* This field is required.

6

Which of the following best describes what you want most in life that this relationship has been keeping you from?* This field is required.

Happiness and contentment

To leave a legacy and be remembered

To achieve all my goals and be successful

To be able to experience true, great love

7

Do you feel like you are in control of the course of your life?* This field is required.

Yes, and I like it that way

Yes, but I’d rather not be

I’m not sure

No, and that’s fine

No, but I want to be

8

If you met a good fairy, who offered to grant you one wish pertaining to your life or self-improvement, what would that wish be?* This field is required.

9

Is there anything else you feel is important for the therapist to know before we start the chat?* This field is required.