🌟 Transform Your Love Journey with Rakihealya: Single to Whole Love Coaching Request Form

1
Name* This field is required.
First Name
Last Name
2
What is your gender?* This field is required.
Female
Male
3
Phone Number* This field is required.
Please enter a valid phone number.
4
How did you hear about me?* This field is required.
How did you hear about me?*Get Married Whole Podcast
Google/Internet search
Friend/referral
Facebook
Instagram
Other
5
What is your age?* This field is required.
18 - 24
25 - 34
35 - 44
45 - 54
55 - 64
65 - 74
75 or more
6
What kind of a relationship are you currently in?* This field is required.
Single
Married
In a serious relationship/Engaged
Noting serious for now
7
How many serious relationships have you had?* This field is required.
None
1 - 3
4 - 6
More than 6
8
What has prompted you to seek relationship/dating coaching? Why do you feel it is the right time for you to seek support in this area?* This field is required.
9
1. What is the primary frustration or challenge you have experienced in your relationships and love life? 2. What are the positive aspects or strengths that you appreciate in your current relationship and love life?* This field is required.
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Small
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Ok
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1. As an individual, what specific goals or outcomes would you like to achieve through coaching? 2. How do you envision coaching supporting your personal growth and development? * This field is required.
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Ok
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Additionally, in terms of your relationship, what specific objectives or improvements do you hope to accomplish through coaching? How do you see coaching enhancing and strengthening your relationship?* This field is required.
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If you are currently in a relationship, what is the duration or length of time you have been together?* This field is required.
Currently not in a relationship
Dating
Less than 6 months
6 months to 1 year
1 to 3 years
3 to 5 years
Less than 3 months
Less than a year
5 - 10 years
More than 10 years
It's Complicated/ Not Sure
13
Have you previously engaged in the services of a life coach or therapist? If so, could you share what aspects worked well for you and what aspects did not meet your expectations or needs?* This field is required.
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If we could wave a magic wand, what do you want your relationships and life to look like in 6 months?* This field is required.
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In what ways do you believe that receiving coaching from Rakihealya could support you in achieving the vision you just described for your relationships and life?* This field is required.
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16
Which of the following relate to you the most?* This field is required.
I've ended my relationships most of the time
My partners have ended the relationship most of the time
Generally both of the sides have agreed on ending the relationship together
Both me and my partners have ended the relationship
17
On a scale from 1 to 5, with 5 being the highest level of commitment, how dedicated are you to taking your relationships and life to the next level at this moment?* This field is required.
1
2
3
4
5
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What does the number you selected on the scale of commitment mean to you personally? * This field is required.How would you interpret and describe the significance of that number in relation to your dedication to improving your relationships and life?
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Is there anything specific you would like to cover in our session?* This field is required. Please feel free to share any specific concerns, questions, or areas of your life or relationships that you would like to explore or discuss.
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🌟 Transform Your Love Journey Coaching Appointment Request* This field is required.Take the first step towards transforming your love journey with Rakihealya. Request a coaching appointment today and unlock the potential to create a fulfilling and wholehearted relationship.
21
Email
example@example.com
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