Questionnaire for Intimate Relationship Breakthrough Session

 Congrats on saying 'yes' to gifting yourself your Intimate Relationship Breakthrough Session.

I look forward to the possibility of supporting you!!  
All of your answers to the questions below are confidential.

Thanks for taking the time to complete this form. Your answers help me to serve you better during your session.
The more questions you answer, the better I can serve you.

Please set aside up to 60 minutes for your session as if we are both feeling connected we may easily go over the 30 minutes (complimentary) time.

I am on a mission to support couples in  divorce proofing their marriages & reigniting intimacy,
Blessings,
Vireo

Pleasure Coach Vireo
780 905 4912
email pleasurecoachvireo@gmail.com
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Email *
Full name (first & last) *
What is your name on Facebook (if you are on FB)?
What is your cell phone number and/or landline? (please indicate if it is cell/landline)
How old/young are you?
Clear selection
What is your relationship status (check as many as apply)?
How many years have you & your partner been together or were you together? *
What is your vision / goal / dream for your intimate relationship? *
What are you yearning for in your intimate relationship? *
What is your bigges
Clear selection
How often are you & your partner currently having sex, making love?
Clear selection
How satisfied are you currently with your sex life in your intimate relationship?
Not at all
Very satsfied
Clear selection
What are some of the reasons that you gave your relationship this rating?
How satisfied do you feel your intimate partner is, with your sex life in your intimate relationship? Frequency? Connection?
not at all
Very satsfied
Clear selection
What are some of the reasons that you gave this rating?
What holds you back? What are your biggest blocks, challenges/biggest struggles/ biggest obstacles, regarding pleasure, sex & intimacy in your relationship? *
What are some limiting beliefs that block you from having more pleasure, connection, better sex & intimacy in your intimate relationship (example: undeserving, not good enough, shame, guilt, fear of....)? *
What has changed in your intimate relationship?
What courses, workshops or counselling have you already invested time, energy & money in regarding your communication, connection,  intimacy & sex in your relationship with your partner?
How much money have you invested on your relationship in the past (books, courses, workshops, counselling, retreats etc)?
What’s your biggest reason for booking your Intimate Relationship Breakthrough Session with me, Vireo?  If I could wave a magic wand... *
On a scale of 1-10, where 1 is 'not at all' and 10 is 'completely', how committed are you to doing whatever it takes to reignite intimacy in your relationship, improving communication & the desires you mentioned above? *
Not at all
Completely, I am all in.
On a scale of 1-10, how open are you to receiving support and being coached around reigniting passion in your sexuality, deepening communication,  & increasing intimacy & connection in your relationship? *
Not at all
I am all in.
On a scale of 1-10, how able are you to invest time, money and energy into divorce proofing your relationship/marriage, improving your sexuality with your partner & increasing intimacy in your relationship? *
Not at all.
I am all in.
Anything else that you want me to know before we meet on zoom for your session?
Which of the following have you checked out? *
Required
Congrats on getting clear your pathway to more connection & intimacy with your partner!
Make sure that you arrive on time for your session. Please have pen, paper & water (not tea or coffee).  In order to build new neural pathways in your brain during your session, your brain needs to be hydrated.
See you soon.
Namaste,
Vireo
A copy of your responses will be emailed to the address you provided.
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