Men's Support Group Coaching Program Questionnaire
Hello, and thank you for taking the time to sign up for this men's online support group! Please fill out this information so that Dr. Silas can ensure you are the right fit for this group and to ensure that you get the most value out of the group. These group calls will take place on Wednesdays from 4-5pm EST.
What is your first and last name?
When is your birthday?
How would you rate your self-care (1 is very low, 5 is very high)
Describe yourself as a child.
What messages did you receive while growing up about what it means to 'be a man?'
What is your current relationship status?
In a committed relationship
Fast forward one year from now...what do you want for yourself?
Fast forward 5 years from now...what do you want for yourself?
How do you want to be remembered? What's your legacy?
What's one thing you would accomplish if you knew you could not fail?
What's your biggest barrier at this time?
Where (what areas) in your life do you feel stuck?
Current job, profession or career
Most intimate personal relationships
Relationship with finances
Mental health and emotional wellness
Physical health (diet, exercise, etc.)
Friends and community
Ongoing educational pursuits
Hobbies, fun, travel, enjoyment
What is going well for you in your life?
Tell me three things that you are passionate about. What do you LOVE to do?
What are three things that drain the life out of you?
What do you consider the major cause of stress in your life?
What are your top 3 goals for this program?
What topics would you like to cover during the duration of this program?
How frequently would you prefer this group meet?
Biweekly (every other week)
Is there anything else you want me to know before we get started?
Please note the Zoom link to the group sessions will be included in a subsequent email.
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