Surviving Toxic Relationships with The Matadoras
Healing Journey Intake Form
Name
First Name
Last Name
Email
example@example.com
Do you believe you’ve been (or are currently) in a toxic or emotionally abusive relationship?
Yes
No
Maybe
What types of relationship dynamics have affected you most?
Romantic partner/spouse
Parent or family member
Religious or spiritual leader
Friend or co-worker
Other
How would you describe your current relationship status?
Still in the relationship
Recently left (within the past 12 months)
Left 1–3 years ago
Left more than 3 years ago
The person is no longer in my life
What best describes your current season?
I feel stuck and unsure of what’s happening
I know I need to leave but feel overwhelmed
I’m in the healing process but still struggle
I’ve done a lot of healing and I’m ready to rediscover myself
Other
Are you open to a Christ-centered approach to healing?
Yes, I prefer it
Yes, I’m open to it
No, I prefer a secular approach
Have you ever worked with a coach, counselor, or support group before?
Yes
No
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
If yes, what helped most—or didn’t help?
What kind of support would you find most helpful right now?
Safe space to talk without judgment
Learning to set and hold boundaries
Rebuilding confidence and identity
Faith-based encouragement and prayer
Tools to co-parent or manage toxic people
Guidance for midlife reinvention
Support from women who “get it”
Other
What type of coaching are you most interested in?
Small group support
One-on-one coaching
Not sure yet, just exploring
How ready are you to invest in your healing and growth?
I’m just learning about it
I’m ready to take next steps with support
I’m committed and looking for a group now
What’s one word or phrase that describes what you’re longing for right now?
Would you like us to schedule a free 30-minute discovery call?
Yes
No
Is there anything else you’d like to share with us or would like us to be praying for as we walk beside you through our podcasts or other resources?
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