Welcome to "Loving Relationships for Women of Color™".

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The following questionnaire will help us discover if we are the right fit for helping you build your dream love life. The calendar link will be available once we have read your application (please be patient). Incomplete applications will not be considered. We look forward to making the rest of your love life the best of your love life. Please be as forthcoming and candid with your answers as possible. Your information will never be shared without your consent.

Email *

First Name *

Last Name *

Preferred Name *

Preferred Pronouns *

Age *

Date of Birth *

YYYY

Referred by: *

Cell Phone Number (Only used in case of last-minute changes or disconnection. Will not be shared.) *

Occupation *

Any Health Problems? *

Any physical issues or personal areas of concern? *

Addictions - Drinking, Smoking, Drugs, Gambling, Compulsive Behavior

Anxiety - Stress, Fears, Phobias, Panic Attacks, Guilt, Relaxation

Eating Dysfunction - Food/Diet, Weight Problems, Anorexia, Bulimia, Ability to Exercise

Depression - Confidence, Self-Esteem, Motivation, Achieving Goals, Procrastination

Career Issues - Interview Skills, Nerves, Public Speaking, Concentration, Exams, Memory, Driving Skills

Sexual Problems - Fertility, IVF, Conception, Pregnancy, Birth Issues

Pain Control - Hearing, Sight/Vision, Mobility, Skin Problems, Hair Growth

Relationships - Childhood Problems, Sleep Problems, Conflict, Loneliness, Family Issues, Marriage Issues

Other:

Required

Have you ever or are you currently engaged in clinical therapy? If yes, please state the amount of time and how long ago your last session was. (If you prefer not to answer please indicate.) *

What is your current relationship status? *

Single

Married

In Relationship

Divorcing

Widowed

Other:

What do you want your relationship status to be? (In one or two words.) *

If your relationship status and what you desire are different, what do you think is standing in the way? *

What would you like to identify as the main challenge you would like to address? *

How has this challenge in your love life been impacting the rest of your life? I.e. job performance, finances, family issues, depression, health, etc. *

Is there anything you would like to share about your upbringing and its impact on your love life today? *

What are you hoping to get out of coaching? *

What are some other things you have tried? *

Are you looking for a 1-1 coaching structure or would you prefer to start out learning with a community? *

What are some practices/habits you currently have that support your mind, body, and spiritual health? *

If you could wave a magic wand, what would be true for you in your love life? *

Describe your love life without any challenges in your way. *

How serious are you about having what you want? *

Still not sure it could ever happen.

I have zero doubts I will have a beautiful love life. I deserve it.

What do you foresee happening if you do nothing? *

Are you currently in a position that would prevent you from being able to invest in yourself financially for this life transformation? *

Yes

Required

If your answer was "yes" to the above, please explain. *

Are you currently in or were you previously in a relationship where your emotional or physical wellbeing was compromised? (Please explain.) *

How would you describe where you are now on your journey of recovery? *

Very stuck, afraid, and unsure what to do.

I am freed and ready to do what it takes to have what I want.

Is there anything in your life currently that would prevent you from being able to take full advantage of a 12-week program for shifting your love life? If "yes", please explain in detail. *

Do you identify yourself as a survivor of domestic abuse who is in recovery? *

Yes

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