WISE-CPR Intake Form

Center for Passionate Relationships Intake Form

* Indicates required field

Name *

First

Last

Date of Birth: MM/DD/YYYY *

Email *

Is it okay to send you email at this email address? *

Phone Number *

Is it okay to leave a message/voicemail at the phone number that you listed? *

Address *

Line 1

Line 2

City

State

Zip Code

Country

How did you hear about us? *

Are you in a committed relationships? *

What's your relationship status? *

Unattached / Single Dating Engaged Married

If you're in a committed relationship, how long have you been in the relationship? *

Family of Origin Information *

Are there any current life transitions or major problems/challenges that I should be aware of? *

How did the two of you first meet? *

What do you consider to be the strengths of the relationship? *

What do you consider to be the growth areas of the relationship? *

How do you currently manage conflicts? *

If engaged, why have you decided to marry at this point in your lives? *

If engaged, what are your expectations from marriage? *

Tell me five aspects of your personal/professional life, past or present, of which you are most proud. *

Are you aware of any behaviors or beliefs that stand in the way of you enjoying a healthy, loving, and emotionally intimate relationship? *

What are your expectations from our coaching sessions? *

Tell me what I should know about you in order to coach you best. *

How will you know that our coaching has been effective? *

Outside of work hours (during your personal time), how much time do you spend on the computer/smartphone/Internet per week? *

Goals

What are the 3 primary short-term goals that you want to focus on in the next 90 days? *

What long-term goals do you want to focus on in our coaching? (Only choose things that you really want, not what you feel you should do! Also, the short-term goals should support your long-term goals. You should anticipate that long-term goals, as the name suggests, will likely take longer than 90 days to achieve and maintain.) *

Why have you hired me? In other words, what about me, what I offer, my experience, or my style, really works for you? What did you hear that made you pursue coaching, and coaching with me? *

Helpful Information

What do you consider to be your personal and/or professional strengths? (E.g. hard working, organized, good with computers, good communicator, good at building relationships and networking with others, etc.) ? *

What do you consider to be your growth areas? (E.g. poor follow-through, I have to be in control/ in charge at all times, difficulty in working with others, etc.) ? *

What are your favorite pastimes—things you enjoy doing for fun? (name at least 5) *

What motivates you or gives you energy to complete big or challenging goals? (E.g. deadlines, consequences, caffeine, your values, meditation, exercise, being out in nature, status, etc.) *

What three things in your life are causing you discomfort/stress? *

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