Client Application
Please take your time to complete this, perhaps even in stages. Once you set your name and password, you will be able to login to your session to complete the form in sections if you prefer. As you progress, your information will be automatically saved to the system. If you do not have an answer for a certain question, please input "N/A"
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
What kind of work are you interested in?
*
Men's Group
Women's Group
Professional Training
Couples
Individual Session
If you checked Groups or Pro Training, which dates are you interested in attending?
*
What materials of Robert's have you completed reading/listening to?
*
Spiritual Bypassing
Transformation Through Intimacy
Emotional Intimacy
Knowing Your Shadow
To Be a Man
Bringing Your Shadow Out of the Dark
None
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Age
*
Gender
*
Geographic location
*
Occupation
*
Relationship Status
*
Married
Committed Partnership
Single
Divorced
Separated
Number of marriages/pregnancies/children
*
Sexual Orientation
*
Straight
Gay
Bisexual
Other
Back
Next
Save
How did you hear about Robert?
*
What types of psychotherapy or counseling have you done previously, and for how long?
*
What were your primary reasons for seeking therapy, and what were the major issues addressed?
*
Are you on any medications? If so, what are they, and what are they for?
*
Have you been on prescription medications for psychological/emotional challenges?
*
Have you ever been hospitalized for psychological/emotional disorders?
*
Have you ever experienced a bad drug trip and if so, what happened?
*
Do you use tobacco, caffeine, drugs, and/or alcohol? If so, how much and how often?
*
Have you ever had an addiction to substances, porn, sex, eating, etc? If so, how did you work with this and how long has it been since any active addiction?
*
Back
Next
Save
What was your religious upbringing?
*
Current spiritual practice?
*
Are you affiliated with a particular group or religious organization?
*
What were the major challenges in your family dynamics as a child? (Please write at least a half page about this.)
*
Back
Next
Save
What have the major challenges been for you as an adult? (Please write at least a half page about this.)
*
Back
Next
Save
Have you experienced any type of abuse? If so, please describe.
*
Back
Next
Save
Have you ever been convicted of a crime? If yes, please describe.
*
Back
Next
Save
Have you ever attempted suicide? If yes, please describe.
*
Back
Next
Save
Any significant accidents/injuries/illnesses? If yes, please describe.
*
Back
Next
Save
Any military service? If yes, please describe.
*
Back
Next
Save
Are you currently in an intimate relationship?
*
If yes, for how long?
*
Is it committed?
*
Monogamous?
*
Any affairs?
*
If not currently in relationship, how long since your last one?
*
Back
Next
Save
What have been the major challenges for you throughout your history of intimate relationships? (Please write at least a half page about this. You don’t need to list all your past relationships, but rather the psychological/emotional challenges in the main ones.)
*
Back
Next
Save
If you are wanting to work on your current relationship, are both people committed to staying together long-term and going deeper?
*
What are the primary issues?
*
Back
Next
Save
What are the main things you would like to address in your work with us? What are you hoping will happen as a result? (Please write at least a quarter page about this.)
*
Back
Next
Save
If I am referred for work to an MCT faculty member, I agree to my application being shared with them so as to help facilitate such work. Enter initials to agree:
*
I give my permission for the person (or persons) to whom I’m referred to discuss my work with Robert. Enter initials to agree
*
Please email your completed application to
info@robertmasters.com
or submit below.
Thank you!
Save
Submit
Should be Empty: