SMS Questionnaire

Below is the questionnaire we talked about on the phone. Please answer as honestly as
possible and know that all of the information you share with me will be held in the strictest of
confidence. Please share anything else that you think it would be helpful for me to know before
we begin our work together and fill out the questionnaire within 48 hours.

First Name*

Last Name*

E-Mail*

What is your intention for this 3 month period?

Do you have any anxieties or worries about this process?

Please give me a detailed description of your childhood, particularly your relationship with your parents and their relationship with one another.

Have you received counseling/therapy? If so, for how long? How do you feel it impacted you?

Describe your romantic relationship history in detail. What trends have you noticed that carry over from partner to partner?

Where are you currently in regards to romantic relationship? Are you ready for a new partner now or do you feel you need more time?

How do you generally feel about yourself? How would you like to see your relationship with yourself shift?

Are there any past traumas in your life that have affected either your relationship to yourself or to a partner?

Please share anything else that you think it would be helpful for me to know before we begin our work together.