Relationship Assessment Application with Deb Acker
Hello and welcome! Please take a few moments to fill out the below. During your call, Deb will share with you the exact issues she sees that are in the way of creating the relationships you are desiring as well as helping you to put together a plan to change this for good. With this, know, that if Deb believes she can support you and coaching with her is the right fit, she or someone from her team will be in touch to schedule your complimentary assessment. Thank you for being here!
Name *
Phone Number (All calls will take place over the phone, unless you are outside of the United States, in which case, you will meet over Zoom.) *
Email *
How did you hear about Deb? *
What is your current relationship status right now? (Please pick the one that's most applicable for you.) *
On a scale of 1 to 10 (with 1 being miserable and 10 being beyond happy), how happy are you in your current relationship, if applicable? (If not applicable, please leave this question blank.)
Miserable
Love being in a relationship
Clear selection
What do you struggle (or have you struggled with) in your love relationships? (This can include everything from having a hard time meeting people or people always leaving to having a hard time communicating or often feeling invisible or disrespected, and of course, everything-in-between. With this, if you are aware of it, please include the type of partners you attract. (Narcissists, emotionally and/or physically unavailable, avoidant, etc.)) *
How strong is your relationship with your mom (or primary caretaker in this role)? (If she's no longer living, please share how this was when she was alive.) *
Non-existant
We're best friends, and she's everything to me.
How strong is your relationship with your dad (or primary caretaker in this role)? (If he's no longer living, please share how this was when he was alive.) *
Non-existant
We're best friends, and he's my world.
Outside of your love relationships, what are your biggest relationship challenges in your other relationships? (Parents, siblings, friends, children, co-workers/bosses, etc.) Is communicating your needs or sharing your experience when someone hurts you a challenge for you? Do you have a hard time keeping friends or do you always find yourself alone (or like you have to do everything by yourself)? Do you feel singled-out, picked on or like people (or the world) are against you? And, do you often find yourself people pleasing in your relationships, and with this, do you struggle having a sense of self? Do you resent any of your family members or their choices? Also, are you estranged from any of your family members? Please share anything and everything that comes up for you below. *
What other non-relationship/non-love challenges are you having right now that, if you could change, you would? (Health, money, work, business, physical and/or emotional pain, trauma, etc.) *
What have you done to solve your current challenges? (Therapy, Books, One-on-One Coaching, Group Programs, Retreats, Energy Healing, etc.) *
If you were able to solve these challenges, what might your life look like and what might be possible? *
Our commitment to change, changes everything. From 0-10, with 0 being never and 10 being now, how ready are you to invest the time, money and energy needed to create the changes you are desiring? Please note: Packages with Deb start at $5000, and payment plans are available. *
Never
Immediately
Anything else you'd like me to know: *
Thank you for taking the time to fill out this application! Know Deb personally reads through each application, and if it's the right fit, she or someone from her team will reach out to schedule the complimentary assessment. In the meantime, head to her new YouTube Channel, The Relationship Healing Channel for Women, at bit.ly/DebYouTubeChannel, for more awarenesses, tips and healing. Much gratitude!
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy