Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
eg: 04 1234 5678
What is your current challenge
*
Marriage
Find Your Life Partner
Empowerment at Work
How possible does reconnecting with your wife seem right now?
Please Select
1 - Highly Unlikely
2 - Unlikely
3 - It is Possible
4 - Very Possible
5 - Definitely Possible
Have you already tried to fix things on your own?
Please Select
Yes - I've tried everything I can think of
I've tried a few things but nothing's worked
Not Yet - I've been unsure of what to do
If nothing changes in the next 3 to 6 months, what's most at risk for you?
My Marriage
My kids & family life
My peace of mind
My self-worth or confidence
Other
Have you tried other ways to find a life partner?
Please Select
Yes
No
How important is a long-term relationship to you?
Please Select
1 - Not important
2 - Slightly important
3 - Important
4 - Very important
5 - Extremely important
If nothing changed in the next 6 months, what would you most likely feel?
Frustrated or emotionally drained
Worried I'm wasting time
Resigned to being alone
Disconnected from myself
Other
What's been most affected by this situation at work?
My confidence
My clarity or sense of direction
My emotional & physical health
My leadership or reputation
Other
Have you already tried to improve your situation?
I've just tolerated it so far
I've tried managing it on my own
I've sought support at work or externally
Please list the type of support(s) you sought
How important is it for you to address this?
Please Select
1 - Not important
2 - Slightly important
3 - Important
4 - Very important
5 - Extremely important
Message
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