Copy of Quality of Life Survey

Important Information Regarding QoL Study

Please Read: This questionnaire includes 32 questions and takes about 7 minutes to complete.

After you finish, please press "DONE" at the bottom of the screen to ensure your answers are recorded.

These questions are highly confidential. Unless you include your first and last name, I will be unable to interpret your results.

Important: What you receive at the end are not your results—just your answers. I will personally review and share your actual results with you.

If you choose to schedule a consultation, I will need your full name to prepare a custom plan.

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* 1. Are you a Member of MeDiCo (a Divorce Coaching Program)

Yes

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* 2. Please rank needs or personal development skills you would you like to develop in the next year.

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* 3. To receive your score please Enter Your First and Last Name

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* 4. I have taken this survey - Purpose here is to be able to separate this survey from the same survey you may have taken perhaps 3 months ago or 6 months ago

First Time

Taken it Once Before

Taken it Twice

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* 5. I have been separated for

0 to 3 Months

3 to 6 Months

6 to 12 Months

12 Months to 2 Years

2 or More Years

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* 6. I'm actively dating casual or long term

True

False

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* 7. Age

20 to 25

26 to 35

36 to 45

46 to 55

Over 55

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* 8. How much have you accepted your marriage is over

I keep trying to get her back

I'm starting to lose hope

I know it's over and am hurting, now I gotta focus on myself and may date

I've reached full acceptance of my circumstances and am OK with it

I'm thriving in this post divorce world. Wouldn't take her back

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* 9. I'm embracing the Single Life

No I want my wife back

I don't want to be single period

Neutral

I am starting to be comfortable single

I'm completely giving it my last hurra as a single male.

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* 10. I feel like no one will ever want me again

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

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* 11. I feel about myself

I hate who/what I am

I'm unhappy with who/what I am

Right now I'm feeling neutral as to who I am

I'm starting to like who I am

I Love Who I am

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* 12. I'm not bragging but I feel I'm attractive to the opposite sex

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

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* 13. I am ready to casually or begin a new long term relationship

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

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* 14. I continue to have flashbacks and wonder where I went wrong here

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

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* 15. When it comes to dating (dating defined as casually or for long term purposes

It's the worst and I really can't find anyone (If Online Dating 0-1 Likes per week)

It sucks the girls are slim pickings (If Online Dating 2-6 Likes per week)

Dunno haven't made up my mind if I like it

I'm getting a couple of dates here and there and a few good ones (If Online Dating 7-14 likes per week)

I'm killing it in the field. So much easier than I remember (If Online Dating 15 or more likes per week)

Not Dating (Please Comment)

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* 16. Right now I just wanna have fun, date, chill, enjoy my time

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

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* 17. My relationship with my children has gotten better since this happened

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

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* 18. Since this happened, my career is starting to hurt

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

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* 19. Do you exercise or workout?

Never, haven't since she told me and am gaining/losing weight

Tried but failed

1 to 2 times weekly

3 to 4 times weely

5 or more times per week

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* 20. Since the Split

I'm highly anxious

I keep getting these visuals of me loosing her or doing something

I've been so angry at her

I have more choices in life

I love my new life

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* 21. Since My Separation

I Gross 50% Less per paycheck

I Gross 30% Less Per Paycheck

I Gross The Same

I Gross about 30% More Per Paycheck

I Gross about 50% More Per Paycheck

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* 22. Since our separation.

I have way too much time I don't know what to do with

I have more time than I'm used to & trying to keep busy

Same amount of time

I'm actually busier

Who ever says down time is a thing. I'm extremely busy

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* 23. I'm currently living

I'm pretty much homeless and not saying with anyone

We're cohabitating

I'm staying with a friend/family

I am renting out a place

Bought my new place

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* 24. Please Rank What's Been The Hardest Part of Your Divorce

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* 25. During my divorce, the Police have been called

True

False

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* 26. If Police Were Called

I was arrested

She Was Arrested

No One Was Arrested

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* 27. How long Did I wait until I dated again (casually or long term)

Haven't way too soon

7 Months to 1 year

Began Immediately (from first day to 3 Months)

4 Months to 6 Months

Over A Year

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* 28. If I could be any famous actor or character in a movie/series, I would like to be and why?

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* 29. I've sought some kind of 1 on 1 help for what I'm going through.

Yes

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* 30. I've seen YouTube videos of the MensDivorceCoach Channel (formerly ReneSanceMan)

True

False

What is that?

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* 31. I have thought about hiring a Divorce Coach

Strongly agree

Agree

What's a Divorce Coach

Disagree

Strongly disagree

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* 32. What has stopped you about reaching out to Rene as a Divorce Coach

Just too salesman like

I just havent gotten around to it

I didn't know there was such a thing

I don't want to feel the work

It's all too real right now

I'm afraid

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* 33. Please Click Here to Make a free 1 on 1 If you're making a 1 on 1 we do a little scientific analysis as to your needs. Feel free to tell us your divorce story. Where' you're at, challenges, hopes, disappointments. No obligation, I just like to know your strengths.