Answer from where you are today, no judgment, no pressure.
Your Information:
Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Occupation
Family Orientation
Please Select
Single
Married
Living with partner
Living alone and in a relationship
Do you have children?
Yes
No
How many children do you have and how old are they?
Are you currently in therapy?
Yes
No
How often do you see your therapist?
Self Assessment:
How would you rate your relationship with yourself?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What would make it a 10?
How would you rate your positive coping skills when things get tough? (In other words, how often do you turn to things like meditation, exercise, and self-care when you’re feeling bad?)
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What would make it a 10?
How would you rate your ability to deal with anger?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What would make it a 10?
How would you rate your relationship to your family of origin?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What would make it a 10?
How would you rate your relationship with food, alcohol, and/or drugs?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What would make it a 10?
How would you rate your career?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What would make it a 10?
How would you rate your relationship with money?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What would make it a 10?
How would you rate the friendships in your life?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What would make it a 10?
How would you rate your romantic life?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What would make it a 10?
How would you rate your ability to communicate effectively?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What would make it a 10?
Course Intentions:
What is the main reason you want to participate in this course?
What do you hope to walk away with from this course? What outcomes would make it feel like a success?
Is there anything else you would like me to know?
Submit
Should be Empty: