Love Ready Group Program — Screening & Intake Form
Share your contact details, relationship background, and readiness so we can assess fit for the program.
This screening form helps us understand where you are in your journey and whether the Love Ready group program is the right fit for you at this time. All responses are confidential and protected under applicable privacy laws. Completion of this form does not guarantee enrollment.
Contact & Basic Information
Full Name
*
Preferred Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
City and State
Preferred session format
In-Person (Southlake office)
Virtual (Zoom)
Hybrid
How did you hear about the Love Ready program?
Social Media
Friend or Referral
Therapist or Provider
Google or Web Search
Other
Relationship Background
Current relationship status
Single not dating
Single actively dating
Recently ended a relationship
Complicated or other
How long have you been single?
Less than 6 months
6-12 months
1-3 years
3-5 years
5+ years
Briefly describe your relationship history
What has been the most significant pattern or challenge in your past relationships?
Readiness and Goals
Why are you interested in the Love Ready program at this time in your life?
*
What do you hope to walk away from this program with?
How ready do you feel to be in a committed relationship today?
Not ready
1
2
3
4
5
6
7
8
9
Extremely ready
10
1 is Not ready, 10 is Extremely ready
How willing are you to be honest and vulnerable in a group setting?
Not willing
1
2
3
4
5
6
7
8
9
Very willing
10
1 is Not willing, 10 is Very willing
How committed are you to doing the between-session work?
Not committed
1
2
3
4
5
6
7
8
9
Very committed
10
1 is Not committed, 10 is Very committed
Which describes where you are right now?
I know I want to be married but feel stuck
I keep attracting the same kind of person
I have done self-work and am ready for a group setting
I want to be more intentional in dating
I am healing from a breakup or loss
I want community with other women
I want to understand my attachment style
I feel ready but want reassurance
My faith and values are central to my approach
After submitting, you will be taken directly to Part 2 to complete your screening. This should only take a few more minutes.
Continue to Part 2 →
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