Hold Me Tight® Intake Form

Your Name*

First Name Last Name

Partner's Name*

First Last

Email*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Number Type

Okay to leave a message?

Preferred method of communication

I am:

How many years have you been with your partner?

Please rate the following four questions on a scale of 1-5, with 1 being a low level, and 5 being a high level.

How would you rate your ability to communicate your needs and wants to your partner?

How would you rate your level of emotional intimacy and connection with your partner?

How would you rate your level of sexual intimacy with your partner?

How would you rate your ability to manage conflict within your relationship?

What do you perceive as the biggest issue or problem in your relationship?

If those issues were solved, what would your relationship look and feel like?

What do you hope to get out of this workshop?

How did you hear about this workshop?