Sharon K Chapman- Relationship Coach

Confidential Client Pre-Questionnaire

Please complete the following sections before our appointment. Thank you.

Personal Details

Your Full Name*

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Your Email Address*

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Your Mobile Number*

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Date of Birth*

Please enter your date of birth (Enter date of birth in “dd/mm/yyyy” format. If your birthday is May 3, 1980, enter 03/05/1980).

Your Address*

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Your State and Country*

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Occupation*

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How did you hear about me or who referred you? ColleagueFacebookFamilyFriendInstagramInternetPrevious clientYouTubeOther

How can I help you?

What would you like help and support with? Finding good relationships based on respect, trust and joyImproving your current relationship/sLeaving a relationship/sImproving your relationship with yourself

What are the 3 main challenges you’re currently experiencing with your relationships?*

How long have you been experiencing these challenges?* 0-3 months3-6 months6-12 months12-24 months2-5 years5-10 years10-20 years20-30 years30-40 years40+ years

Are there any coaches, counselling, or tools you have tried previously to resolve these issues?* CoachingCounsellingPsychologistPsychiatristSelf-help booksWorkshopsSeminarsGroup sessionsOnline tutorialsYouTube videos

About You

Which of these do you do or use frequently (i.e. daily or several times a week)? *AlcoholAttracting drama filled peopleFood – Emotional eating / overeating / Binging / Eating DisorderGamblingInhaling petrol / or solventsInternet surfingLots of short term relationshipsMany sexual partnersNeed for pain killersObsession with a particular practice or hobbyOver exercisingOverspending moneyOverworkingPornographyRecreational drugsSelf-harmSocial MediaSmokingStaying super busy

(Select all those which apply)

Are you currently on any medications (prescribed pain killers or anti-depressants?)*

If none, type "NA".

How long have your been taking the medication?**

If you answered NA to the previous question, type "0".

Are you currently experiencing any of these?

Which emotions are you feeling right now? *AngerAbandonmentBoredBelittledBetrayedConfusedCriticizedDisappointedExhaustedFearGriefGuiltHelplessHopelessnessHumiliatedHurtIgnoredInsecureIsolatedLonelyMisunderstoodNeglectedObligatedOverwhelmedResentmentSadShameTrappedUnappreciatedUncertainWary

(Select all those which apply)

Which of these physical symptoms are you experiencing right now Aches and pains such as headaches, backaches, stomach aches, muscle tensionConstipation and/or diarrheaDigestive issuesInsomnia or trouble getting to - or staying asleepSkin conditions -dermatitis, eczema, psoriasis, skin rashes, broken capillaries or reddened skinSusceptible to cough, colds and fluOther

Which of these are you experiencing right now?*Anger, irritability and mood swingsBursting into tears and crying for no apparent reasonConfusion and difficulty concentrating, focusing or rememberingDiminished interest in everyday activities or depressionDesire for revenge / plotting it in your head of how to ‘get back’ at somebody or group of peopleDiminished interest in everyday activities, losing your ‘zest for life’Dumping your emotions on people around youEasily startled by noises or unexpected touchFear or a constant feeling of being unsafeFeeling disconnected or numbIrritability, restlessness, with sudden outbursts of anger or rageLoss of beliefs towards a religion or belief systemLoss of a sense of order & fairness in the worldNightmares and / or flashbacks – feeling like a bad event is happening or could happen againOCD tendencies (Obsessive compulsive)Regular bouts of feeling blue, anxiety or depressionUnpleasant past memories resurfacingWanting to bury your head underneath the covers for days at a timeWithdrawing from others, isolating yourself & feeling nobody understands what you’re going through

(Select all those that apply)

Did you experience any of these in your childhood?

In my childhood (up until the age of 16 years) I experienced:*Adoption or unknown identity of family members and relevant circumstancesA humiliating or deeply disappointing experienceA move to a new location (or many regular moves)Any form of physical pain, injury or illnessA physical impairment of any kind (stuttering etc)Being fired from a job / laid off / redundancyBeing held against your will / abduction / held hostageBeing rejected by a person (or group of people)Bullying / teasing of any kind (physical appearance / religious or cultural beliefs, impairment)Burglary or home invasionCar accident or any form of physical accident (such as motorbike, horse-riding etc)Caregivers who used alcohol / drugs on a regular basisDeath of a friend, colleague, close family member, or petDifficult or traumatic pregnancy / childbirth / aftercareDiscovery of an injured, sick or deceased person / animalDiscovery of a life-threatening illness or disabling condition (yours or a family member)Divorce / separation of caregivers or close family membersDomestic violence / witnessing a violent act in or out of the home environmentExcessive punishment of a mistake madeExperiencing a natural disaster (such as a flood, fire, earthquake, tornado etc)Emotionally / mentally unstable parent/s or caregiversEmotional, verbal, physical or sexual abuseFailing an exam or any form of educational/career pursuitFear of public speaking due to unpleasant experienceFlying in an aeroplane or being in a confined space without an exit availableGiven too much responsibility as a child to look after yourself, siblings or care-giversHospitalization for any reasonIntrusive medical proceduresLearning difficulties or impairment in schooling yearsLoss of financial funds due to scamsNeglect or abandonment (or being left alone for long amounts of time)Parent or caregiver being your ‘best friend’ and sharing too much information with youRaised in foster care or with carers that were not my biological parentsSeparation from parents or family members for any length of timeThe breakup or loss of a significant relationshipThings happening out of your control / expectantly without explanationWitnessing or being part of terrorism or mass disasterWitnessing or being part of any violence or war

(Select all those which apply)

Your Success

Regarding Relationships (with yourself and others), would you like to learn more about:*Letting go of resentment with yourself or anybody else?Communicating your thoughts, feelings, wants and needs in a loving way so that you are listened to, heard and respected?Knowing how to deal with conflict in a loving and compassionate way?Quick, easy and effective ways to reduce stress that can be done in the car, at home or any social environment?Strengthening your personal boundaries, not feeling obliged to do things to ‘keep the peace’ and feeling comfortable saying ‘no’?Deepening your connection and intimacy with those you care about?Feeling ok with sharing vulnerable aspects of yourself?Listening to your intuition, trusting yourself so you know who to share your innermost thoughts and feelings with?Knowing what ‘red flags’ are in any relationship and how to manage these?Understanding the different ways people react to stress or an upsetting event and how they display it?Learning what your main priorities are when in an intimate relationship – and how to discover a partner’s so you can experience deep trust and love?Understanding your life values and ensuring your life is guided by them?Learning where low self-esteem comes from and how to resolve it?How to bring more laughter, fun and joy into your relationships?Asking and receiving deeper love, intimacy and physical pleasure?How to ‘be on the same page’ in a Relationship, with clear expectations and celebrating your successes along the way?Give and receive more affection, compliments and appreciation for your contribution and efforts?

(Select all those which apply)

What does success look like for you? *

If we were celebrating the successful resolution of your relationship issues today, and you could experience exactly what you want to experience, what would that look like? Please be as descriptive as possible!

Thank you for your time and honesty, I look forward to assisting you soon.

Sharon