Discover US Input

Pre-Program Confidential Input

* Indicates required field

Name *

First

Last

1 - What is your goal in participating in the Discover US program?
(Answers will be kept confidential)

Choose One *

I am hoping to improve an already good relationship. (Seeking connection) I am seeking growth to help rebuild a relationship that has been struggling. (I want to reconnect) I am seeking awareness to better understand who we are before making a major commitment. I am seeking information to see if we can heal a dysfunctional relationship. I am hoping that the information will make it clear that we are too dysfunctional and that we should disconnect.

Comment - Goal *

2 - What is your level of desire to enthusiastically participate in the program?
(Answers will be kept confidential)

Choose One *

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

Comment - Participation *

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 to know prior to starting?
(Statements will be kept confidential)

Comment *

Pre-Program Confidential Input

1 - What is your goal in participating in the Discover US program?(Answers will be kept confidential)

2 - What is your level of desire to enthusiastically participate in the program?(Answers will be kept confidential)

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

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

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

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

1 - What is your goal in participating in the Discover US program?
(Answers will be kept confidential)

2 - What is your level of desire to enthusiastically participate in the program?
(Answers will be kept confidential)

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

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

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

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