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.
Email address *
What is your first and last name?
Your answer
When is your birthday?
MM
/
DD
/
YYYY
How would you rate your self-care (1 is very low, 5 is very high)
Describe yourself as a child.
Your answer
What messages did you receive while growing up about what it means to 'be a man?'
Your answer
What is your current relationship status?
Fast forward one year from now...what do you want for yourself?
Your answer
Fast forward 5 years from now...what do you want for yourself?
Your answer
How do you want to be remembered?  What's your legacy?
Your answer
What's one thing you would accomplish if you knew you could not fail?
Your answer
What's your biggest barrier at this time?
Your answer
Where (what areas) in your life do you feel stuck?
What is going well for you in your life?
Your answer
Tell me three things that you are passionate about.  What do you LOVE to do?
Your answer
What are three things that drain the life out of you?
Your answer
What do you consider the major cause of stress in your life?
Your answer
What are your top 3 goals for this program?
Your answer
What topics would you like to cover during the duration of this program?
Your answer
How frequently would you prefer this group meet?
Is there anything else you want me to know before we get started?
Your answer
Please note the Zoom link to the group sessions will be included in a subsequent email.
Your answer
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This form was created inside of Tipping Point Wellness.