Are you experiencing relationship issues?
Yes, frequently Occasionally Rarely Not at all
How would you describe your childhood?
Traumatic Unstable Average Happy
Do you have trust issues?
Yes, significant Somewhat Rarely Not at all
How often do you communicate feelings?
Very often Sometimes Rarely Never
Interested in improving relationships?
Yes, definitely Maybe Not sure No, thanks
All set, how can we reach you?
Name
Email
Phone
(Details here)
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