Please fill in the form, and help us empower you to create a relationship of your dreams.
Greetings, Dear Friend!

Thank you for your interest in Karezza Coaching.

In order to be able to serve you to the best of our ability, we need to know a little more about you. For this reason, we created this survey, which is designed to give us the information we need to offer you the best guidance possible, and, at the same time, provide you with clarity about where you are and where you wish to be.

So taking this survey is a practical step in moving you forward towards the realization of your dreams.

We can only give you our best if you give us your best. Please take your time when completing the survey, and answer the questions to the best of your ability. Thank you.

With Love,

Evita Ramparte

We promise that your information is 100% confidential, protected, and never disclosed. Your contact details are required, so we can send you highly valuable content, invitations to exclusive events, and special gifts.
Contact Information
First & Last Name *
Email: *
Your country *
Are you...
Clear selection
What do you do for a living?
Answer to the following questions
Please take your time and answer the questions in detail. It will help you and us to have more clarity about what's stopping you, and how we can help you move forward.
1. What are the 5+ PRIMARY problems / challenges / frustrations you experience in your love life and intimate relationship?
2. What are the 5+ SECONDARY problems / challenges / frustrations caused by your main 5 problems / frustrations / challenges?
In other words what are the IMPLICATIONS of your main problems? Example: I always experience too much drama in a relationship >> IMPLICATION: I cannot be vulnerable, committed, and experience deep intimacy with a partner.
3. What have you tried to solve these problems / challenges / frustrations that DID NOT work?
4. What have you tried to solve this problem that ACTUALLY WORKED?
Even just a little.
5. What are you most worried about / afraid of in your love life?
6. What are you afraid will happen if you donโ€™t solve the situation as soon as possible?
7. What are you willing to do to solve this problem?
8. What would it take for you to find happiness in your love life this year? What are you willing to give up?
9. Do you carry any anger, envy, or resentment? If so, as a result of what or whom?
Ex.: My family members who think I am crazy. - Evita Ramparte on Facebook ;D etc.
10. What are the 5+ MAIN dreams / desires / ambitions you have for your love life?
Be specific and prioritize them, please.
11. What would change if you accomplished your dreams / desires / ambitions?
12. What is your secret desire?
We are asking because maybe we can help you with that!
Complete the following sentences.
1. I feel I am not good enough to...
2. I have no idea how to...
3. I am not having the results I desire with...
4. I have the dream/desire of...
5. I value...
6. I am eager to defend the idea that...
7. I am afraid that...
Why are you interested in working with us?
1. In what ways do you think our Karezza Coaching could help you? What are your expectations?
2. If you could ask us ONLY ONE question what would it be?
3. How did you find us?
About Your Relationship:
Briefly describe your relationship as it is now:
If you are single describe some experiences, or your single life as it is.
Briefly describe your relationship as you would want it to be:
If you are single, please describe the relationship of your dreams.
What is the PRIMARY purpose of your relationship?
What is the SECONDARY purpose of your relationship?
Tell us more about yourself.
Which of the following describes you?
Clear selection
Please check all statements that apply to you.
๐Ÿ’› Congratulations! You have reached the end of this survey. ๐Ÿ’›
This is the first step to empower you in your journey!

Click the "SUBMIT" button below, and we will contact you soon.
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