Confidential Intake Form For Open: A Group Program for Avoidants
If you want to be in my 10 week group program, please fill out this form to the best of your ability. This program requires a serious commitment emotionally, physically, mentally and financially. I am being upfront with how challenging this will be, however you will be rewarded way beyond what you invest in this program! Do everything asked of you and you will experience massive and amazing change.

Once you complete this form, I will email you to schedule a Discovery Session.

Email address *
Name *
Your answer
Phone number (for Discovery Session) *
Your answer
Age range *
What's your relationship status? *
Please describe one of the ongoing/repetitive issues you have had in dating or relationships. *
Your answer
How often do you experience anxiety? *
How do you respond to the potential for a serious relationship? *
Briefly describe a situation where you felt rejected and how you responded. *
Your answer
How fearful are you of abandonment/loss? *
Not much
Extremely
Would you describe yourself as independent/very self-sufficient? *
Have you ever had a needy partner? If so, how did it make you feel? *
Your answer
Do you feel emotionally connected to yourself? *
How hard is it for you to be emotionally intimate with another person? *
Very easy
Very hard
How long was your longest romantic relationship? *
Your answer
Do you feel misunderstood much of the time? *
Do you have a fear of appearing weak or needy? *
Please describe what the word "commitment" means in your personal life. *
Your answer
Regardless of whether or not you are in a relationship, how often do you feel lonely? *
How important is sexual chemistry to you? *
Not important
Very important
Would you say you are a control freak? *
How openly do you communicate with others? Check all that apply. *
Required
How well do you feel others know the real you? *
Not very well--I keep my cards close to my chest
Very well--I'm an open book
What do you hope to get out of this group? *
Your answer
Do you feel like life dealt you a bad hand? *
What is the biggest thing you would like to change about your life? *
Your answer
Will you take suggestions, advice and direction from Tracy and her coaches in this program? *
Is there anything else you feel Tracy needs to know about you?
Your answer
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