Preliminary Questionnaire

Hello Lovely!
Thank you for your interest in working with me as your coach & mentor as you desire to fulfill your life & love goals. By answering each question honestly and thoroughly, together, we can maximize the our time together and develop clear goals and a plan for your personal and relationship success!  I will personally and confidentially review your submission.
Thank you in advance for taking time to complete the questionnaire. I am looking forward to speaking with you soon.
-Teresa Renee

Address

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* 1. Address

I am...

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* 2. I am...

I am...

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* 3. I am...

I have been in my current relationship/marriage for...

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* 4. I have been in my current relationship/marriage for...

Evaluate the following statements.

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* 5. Evaluate the following statements.

  Strongly Disagree Disagree Agree Strongly Agree
I am satisfied with my life and my love relationships
I enjoy my life more when I am in a relationship.
I know what I need in a mate
I know what I can offer, and the value I bring to a relationship
I know what it takes to have a healthy relationship
I am ready to face the truth about myself
I want to change some things in my life and/or relationship but I don't know where to start
I am ready for action and accountability
(6.A.) What are your personal strengths?
(6.B.) What is your greatest strength(s) or asset you can offer in a relationship?

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* 6. (6.A.) What are your personal strengths?
(6.B.) What is your greatest strength(s) or asset you can offer in a relationship?

What problems or challenges are you facing in regard to your life, love, your relationship, and/or with yourself?

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* 7. What problems or challenges are you facing in regard to your life, love, your relationship, and/or with yourself?

Why are you interested in coaching/mentoring?  What do you need help with and/or what are your seeking?

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* 8. Why are you interested in coaching/mentoring?  What do you need help with and/or what are your seeking?

What are your top 3 personal or relationship goals?

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* 9. What are your top 3 personal or relationship goals?

What are you hoping to gain from working with Teresa as your coach & mentor?

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* 10. What are you hoping to gain from working with Teresa as your coach & mentor?

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