Intake form
Dr. Zhana's relationships coaching / education intake form
Email address *
What's your name?
Your answer
How old are you?
Your answer
Where do you live?
Your answer
What's your gender?
Your answer
What's your sexual orientation?
Your answer
What do you do for a living?
Your answer
What's your relationship status?
Your answer
If you're single, when was the last time you were in a relationship? Are you seeing/dating/hooking up with anyone?
Your answer
If you're in a relationship. Provide basic demographic information about your partner (their gender, age, profession). How long have you been with together with this person? Do you live together?
Your answer
Do you have children? If so, how old are they and do they live with you?
Your answer
What are your sexual/relationship issues you wish to get coaching or education on? How long have these been going on for? (Provide as much info as you think is relevant)
Your answer
In your opinion, what is causing these issues? What are the main obstacles standing in your way?
Your answer
How are these issues affecting different areas of your life?
Your answer
What have you done thus far to try and resolve this issue? What did those attempts result in?
Your answer
In your ideal real world, what would your sex and relationship life look like?
Your answer
How committed are you to working on resolving your sex and relationship issues?
Not at all committed
Extremely committed
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