IN WHAT AREA DO YOU NEED THE MOST SUPPORT RIGHT NOW? 

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* 1. What is your most dominant concern right now?

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* 2. Do you feel this concern is more of a personal issue or a relationship issue?

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* 3. Which category would this concern most likely come under?

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* 4. What form of support would be most helpful to you? 

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* 5. How long of a program would you be interested in? 

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* 6. Do you have anything else to add?

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* 7. Please provide your name and email address to be entered in the drawing for an Amazon gift card.

Name:

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* 8. Email address:

Thank you so much for taking part in this survey!
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