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Members
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* Indicates required field

Name *

First

Last

Email *

1 - On a scale of 1 to 10, how emotionally secure do you feel in your daily life?

Choose One *

1 2 3 4 5 6 7 8 9 10

Comment - Emotionally Secure *

2 - How do you typically talk to yourself when feeling insecure?

Choose One *

I'm excited to participate. I'm looking forward to participate I'm willing to participate. I'm hesitant to participate.

Comment - Self-Talk *

3 - How prepared are you to face your own issues without getting defensive?
(Answers will be kept confidential)

Choose One *

I am aware that I have lots to heal and will be curious. I am not perfect, but I do believe that I have everything under control. I believe that most of our problems are because of my partner. I trigger easily and will likely get defensive.

Comment - Defensive *

4 - How prepared are you to hear your partner disagree with your perspective?
(Answers will be kept confidential)

Choose One *

I will openly receive the feedback and consider their perspective. I am willing to listen and will do my best to not get defensive. It won't be easy. I will likely trigger and get defensive. I am not interested in what they have to say about me.

Comment - Perspectives *

5 - Are there any children or family members involved?
(Please explain in comments if necessary.)

Choose One *

We have children in the home. We have children but not in the home. We have family members in the home. We have family members who interfere. There are no outside people/factors that need to be considered. There are multiple outside people/factors that need to be considered.

Comment - Children/Family/Outside Factors *

Do you have anything that you would like me (the host) to know?
(Statements will be kept confidential)

Comment *

Submit

A Conscious Partner - Development Team

A Conscious Partner is the fun, affordable and interactive way to
discover more about yourself and others, and to answer the question:
"Why do the same things keep happening to me"!

Please feel free to contact us at any time with any questions that you may have!

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Programs
Getting Started
Members
Quick Links
- ACP TeamZ
- ACP Videos
- Personality
- Reviews
- Join Us
- Worksheets