6 WEEK INTAKE ASSESSMENT

Please complete this brief assessment.

* Indicates required field

Name *

First

Last

Age *

Email *

Current Relationship Status *

Phone Number *

How Long Have You Been Single? *

What Are You Looking For In A Spouse (Financially, Physically, Spiritually, Emotionally)? *

What Are You NOT Looking For In A Spouse (Financially, Physically, Spiritually, Emotionally)? *

What are your insecurities when it comes to dating, love, and relationships? What Are Your Past Dating Trauma/Dating Patterns in Men & Yourself You've Noticed?? *

What Was Your Childhood Like? Childhood Trauma? Relationship With Both Parents? *

Top 3 Things I Like & Don't Like About Myself Are: *

Currently Abstaining From Sex? Virgin? Sexually Active? *

What's Your Threshold For Discomfort/Growth/Change/Pain? Can You Undergo It If You Believe Results Worth It? Do You Shy Away/Avoid It? Run? *

Do You Struggle With Being Vulnerable? How Easy Or Hard Is It For You To Let Your Guard Down & Trust Emotionally? *

I joined this H.I.S. program called _________________________ in order to achieve my desired goal(s) of (list at least 3 specific goals): *

The challenges/obstacles I’ve noticed in trying to reach my goals have been: *

I’ll know I’ve made progress in reaching my desired goals when I start to/when I no longer (i.e. what does “Sexy Me” mean and feel like to you?): *

To Secure Your Half Off Price For The Program Are You Willing to Provide Testimonial on How The Program Is Impacting Your Life Each Week Via Text and/or Video? *

Submit

Please complete this brief assessment.

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