RSA Efficacy Study Intake form (Phase 2)
Please complete this intake form before using this link to fill out the Informed Consent Form (https://tinyurl.com/458nb4mm.   If no time available works for you, please email Houseofalgos@gmail.com to see if we can accommodate another time that does work.  All your information is confidential.   All questions are required with exception to the free write at the end.  If you feel that a question does not apply to you or you don't know what to put down, use the "Neutral" option.

Approximate time to complete all questions is 20 minutes.

Once completed, Please fill out the Informed Consent Form to Proceed:


Do you consent to being added to the AskEzra.info mailing list?  This is optional and does not impact your eligibility for the study. *
I consent to being added to the AskEzra.info mailing list.
Clear selection
Name (will not be published in data set or elsewhere) *
What is your age? (If you are under 18, thank you for your interest but you are not eligible to continue) *
What is your Race/Ethnicity? *
Were you raised in a religious household? *
If so what religion? *
What is your gender? *
What is your sexuality? *
Are you or have you been married? *
Are you currently partnered? *
Are you currently or have you ever seen a therapist?
*
Are you currently or have you ever seen an intimacy coach or sex coach?
*
What is your phone number or way we can get a hold of you  other than your email (instagram, Facebook, Twitter, Tiktok)? *
Agree / Disagree Section
Please fill out this section to the best of your ability by stating "Strongly Disagree", "Disagree", "Neutral", "Agree", or, "Strongly Agree" in response to each statement.  Select the one option that best suits your stance on the provided statement.
You may only pick one option.  If you are feel you do not have an answer select "Neutral" and move to the next question. 
I love who I am. *
I am wanted by others. *
I feel as though others are ok with who I am. *
I like feeling wanted. *
Others are not okay with who I am. *
I am limited by my thinking. *
I can picture the life I want. *
I hate who I am. *
I get good attention. *
I know where to go to find like minded people. *
I am willing to try anything. *
I feel accepted by my family. *
I am not able to do the things I want. *
I can picture my ideal partner.
Clear selection
I know I can accopmlish what I decide to do. *
I can do anything. *
I feel really good about the sex that I have. *
I feel satisfied by sex. *
I can picture growing old with my partner. *
I stick to my goals. *
My internal voice is kind. *
I feel numb. *
I try new things often. *
I feel upset about the things in my life that I can't change. *
I am aware of my emotions. *
Fear doesn't hold me back. *
I feel anxious or depressed. *
I don't let fear stop me from doing exciting things. *
I find it easy to understand my own emotions in the moment. *
I feel good about the things in my life that are not changable. *
I have lots of things I want to try but I'm not ready/scared. *
I feel aware of my body. *
I like the way I talk to myself. *
I feel things deeply. *
I say things to myself that are too mean to say to others. *
I can picture growing old happily.
Clear selection
When something gets in the way of a goal, I find a way around it.
Clear selection
I could live the life I want if only it weren't so scary. *
When I put my mind to something I can always accomplish it. *
I can picture the most amazing sex. *
When I get emotional I rarely see it coming. *
Strong emotions don't stop me from doing what I want. *
Trying new things in the bedroom is fun. *
I am kind to myself. *
Feelings often take me by surprise. *
Trying new things is fun. *
I often struggle to name my emotions. *
I have amazing sex. *
I am not afraid of going after the things I want. *
If I try something new and it doesn't work out that's okay. *
Anything is possible. *
I can picture the most amazing sexual partner. *
I find it easy to read others emotions. *
I am unkind to myself. *
I can do anything others can do. *
I don't give up once I have decided to do something. *
I am kind to others. *
I have trouble envisoning the life I want. *
Few people if any accept me for who I am. *
I quit things that I said I would do. *
I am sexy. *
I identify as transgender. *
I identify as gay. *
I identify as lesbian. *
I identify as straight. *
I identify as a masochist. *
I enjoy fetish sex. *
I Identify as non-binary. *
I identify as a sadist. *
I identify as asexual. *
I identify as greysexual. *
I identify as a kinky. *
I am happy with my sex life. *
I am easily aroused. *
I easily reach climax. *
I am satisfied with my partner(s). *
End of Agree / Disagree Section
Established Questionnaire Section
These questions are part of established research surveys/questionnaires and can help to create statistically significant quantitative data. 
Begin  The Future Scale  
  Directions: Read each item carefully. Using the scale shown below, please select the number that best describes YOU and put that number in the blank provided.   

Credit: AUTHOR: C. R. SNYDER, UNIVERSITY OF KANSAS
I energetically pursue my goals. *
I feel tired most of the time. *
There are lots of ways around any problem. *
I am easily downed in an argument. *
I can think of many ways to get the things in life that are important to me. *
I worry about my health. *
Even when others get discouraged, I know I can find a way to solve the problem. *
My past experiences have prepared me well for my future. *
 I’ve been pretty successful in life. *
 I usually find myself worrying about something. *
 I meet the goals that I set for myself. *
End  The Future Scale  
Begin Personal Growth Initiative Scale
  Using the scale below, circle the number which best describes the extent to which you agree or disagree with each statement.

Credit: Christine Robitschek, Ph.D. 
I have a good sense of where I am headed in my life. *
If I want to change something in my life, I initiate the transition process. *
I can choose the role that I want to have in a group. *
I know what I need to do to get started toward reaching my goals.
Clear selection
I have a specific action plan to help me reach my goals. *
I take charge of my life. *
I know what my unique contribution to the world might be. *
I have a plan for making my life more balanced. *
End Personal Growth Initiative Survey
Begin Subjective Happiness Scale
  For each of the following statements and/or questions, please circle the point on the scale that you feel is most appropriate in describing you.  
In general, I consider myself:
*
Compared to most of my peers, I consider myself: *
Some people are generally very happy. They enjoy life regardless of what is going on, getting the most out of everything. To what extent does this characterization describe you? *
Some people are generally not very happy. Although they are not depressed, they never seem as happy as they might be. To what extent does this characterization describe you? *
End Subjective Happiness Scale
  Below are five statements with which you may agree or disagree. Using the 1-7 scale below, indicate your agreement with each item by placing the appropriate number in the line preceding that item. Please be open and honest in your responding.   
Begin Life Satisfaction Scale
  Credit:  Ed Diener, Ph.D.

     Below are five statements with which you may agree or disagree. Using the 1-7 scale below, indicate your agreement with each item by placing the appropriate number in the line preceding that item. Please be open and honest in your responding.   
In most ways my life is ideal. *
The conditions of my life are excellent. *
 I am satisfied with life. *
So far I have gotten the important things I want in life. *
If I could live my life over, I would change almost nothing. *
End Life Satisfaction Scale
End Supplemental section of intake interview.
Way to stick to it!  Remember to use this link to schedule your 4 coaching appointments in the next 30 day.  Ideally sessions are 1x per week.
Free Write - please write as much or as little as you like about your feelings regarding your level of acceptance of your sex, sexuality, and gender now that you have received the RSA focused coaching experience. (This step is not required.)
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