Intake form
Dr. Zhana's relationships coaching / education intake form
Email address *
What's your name?
How old are you?
Where do you live?
What's your gender?
What's your sexual orientation?
What do you do for a living?
What's your relationship status?
If you're single, when was the last time you were in a relationship? Are you seeing/dating/hooking up with anyone?
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?
Do you have children? If so, how old are they and do they live with you?
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)
In your opinion, what is causing these issues? What are the main obstacles standing in your way?
How are these issues affecting different areas of your life?
What have you done thus far to try and resolve this issue? What did those attempts result in?
In your ideal real world, what would your sex and relationship life look like?
How committed are you to working on resolving your sex and relationship issues?
Not at all committed
Extremely committed
Clear selection
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