Questionnaire.
This questionnaire digs deeply into who you are and how you might be getting in your own way.
Name
*
First Name
Last Name
Email
*
Confirmation Email
Confirm email
Phone Number
*
Please enter a valid phone number.
Age
*
Occupation
*
Height
*
cm
Are you religious?
*
Yes
No
Which religion?
*
Do you attend a place of worship?
*
Yes, regularly
Yes, a few times a year.
No
Do you consider yourself...
Atheist
Anti-theist
Agnostic
Not something you've given any thought to.
Other
Where do you consider yourself philosophically
Do you drink alcohol
Yes
No
Which best describes your alcohol consumption?
Only on weekends
I occasionally have a drink with lunch/dinner
I have a couple to several drinks most nights
Do you smoke?
Yes
No
Only when I'm drinking
Have you used drugs?
Yes
No
Have you experienced any of the following?
MDMA
LSD
Psilocybin
DMT
Other
What other drugs have you experienced?
Please differentiate Ayahuasca if experienced separately from DMT.
What is your sexual orientation?
*
Heterosexual
Bisexual
Bi-curious
Unsure/Openminded
Other
What can you tell us that would convince us that you are ready to form a high quality, long term relationship?
Relationship Status
*
Married, but separated
Divorced
Widowed
Single
Do you have children
*
Yes
No
How many?
Age of children?
Do you want children?
Yes
No
What is the ideal reason to have children?
Why not?
What is the length of your longest relationship?
How would your most recent ex describe you?
Why do you believe the relationship ended?
Why do you think you are not in a relationship?
Is it a possibility that you are getting in your own way when it comes to romantic success?
Yes
No
Have you been unfaithful
Yes
No
What do you believe caused you to be unfaithful?
Has someone been unfaithful to you
Yes
No
On average which best captures how often you date?
Never
Rarely
Most weeks
Several per week
What is your most common first date location?
Are your parents divorced?
Yes
No
No, but should be
Why do you think your parents' relationship ended?
Why do you think your parents' relationship should end?
Did your parents remarry?
Mother Yes
Mother No
Father Yes
Father No
Father No, but has a partner.
Mother No, but has a partner
Do you have a good relationship with your Mother?
Yes
No
How often do you speak to your Mother?
Every day
Once or twice a week
Less than once or twice a week
Do you have a good relationship with your Father?
Yes
No
How often do you speak to your Father?
Every day
Once or twice a week
Less than once or twice a week
Do you have siblings?
Yes
No
Are you?
Oldest
Youngest
In the middle
Do you have a good relationship with your siblings?
Yes
No
Do you have someone you can tell anything and everything to?
Yes, a family member
Yes, a friend
Yes, several friends
Yes my therapist
Yes, several friends and family members
Do you have friends of the opposite sex?
Yes
No
If given the opportunity would these friends have sex with you?
Yes
No
Possibly
Have already had sex with them
Are you still friends with ex's?
Yes, some
Yes, all
No
Do you exercise?
Yes
No
How often do you exercise?
Sporadically
Regularly
I'm a fitness fanatic
What form of exercise do you do?
Do you practice Meditation?
Never tried
Tried, it's not for me
Don't see the point of it
Not as much as I should
I do my best to practice regularly
I have a solid practice
Have you attended any wellness retreats, workshops, or formal counselling sessions?
Please list
Have you been overseas?
Yes
No, but want to.
No, not interested
Where have you been?
If you've lived OS please specify where and for how long.
Which Social media platforms do you use?
Facebook
Instagram
Twitter
TikTok
Snapchat
All of the above
None
Please provide your social handles
These are a great insight for us.
Are you currently using any dating apps?
Yes
No
Which ones?
How did you hear about us?
Submit
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