RCI Pre-Event Survey

The purpose of this survey is to learn more about your needs regarding intimacy after illness, in preparation for my RCI presentation on May 9. Your comments are confidential and individual responses will not be shared with anyone.

1. Are you interested in the topic of intimacy after illness from a personal perspective or as a professional relationship coach?

Are you interested in the topic of intimacy after illness from a personal perspective or as a professional relationship coach? Personal interest - I am a patient or survivor of serious illness

Personal interest - I am the spouse/partner of a patient or survivor

Professional interest

Both

2. How important is it for you to learn more about reigniting intimacy and sexuality after illness:

How important is it for you to learn more about reigniting intimacy and sexuality after illness: not important at all

fairly unimportant

take it or leave it

very important

absolutely important

3. What three intimacy issues or questions concern you (or your clients) most?

What three intimacy issues or questions concern you (or your clients) most?

4. If you or your partner has experienced a serious illness that disrupted your love life, please indicate which illnesses had an impact on you:

If you or your partner has experienced a serious illness that disrupted your love life, please indicate which illnesses had an impact on you: Prostate cancer

Breast cancer

Other

Please specify other illness:

5. Do you and/or your partner find it difficult to openly discuss sexual intimacy issues? How might I help you?

Do you and/or your partner find it difficult to openly discuss sexual intimacy issues? How might I help you?

6. Would you like to learn more about my intimacy coaching at this time? Please enter your first name and email address in the Comments area below if you want me to contact you for a thirty-minute, complimentary break-through Intimacy Discovery Session to help you achieve the level of physical, emotional and spiritual intimacy you want in your life.

Would you like to learn more about my intimacy coaching at this time? Please enter your first name and email address in the Comments area below if you want me to contact you for a thirty-minute, complimentary break-through Intimacy Discovery Session to help you achieve the level of physical, emotional and spiritual intimacy you want in your life. Yes

Maybe

Comments

7. If you would like to be entered in a drawing to win a free copy of my intimacy home study course, “Ten Strategies for Reigniting Sexuality and Intimacy After a Major Illness,” please enter your first name and email address below:

If you would like to be entered in a drawing to win a free copy of my intimacy home study course, “Ten Strategies for Reigniting Sexuality and Intimacy After a Major Illness,” please enter your first name and email address below:

Thank you for responding to this questionnaire!

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