Group Coaching for Singles - Application
Required Required Question(s)
Required 1.

Please provide the information indicated below.
First Name:
Last Name:
Email Address:
emailaddress@xyz.com
City:
State/Province
(US/Canada):

Required 2.

Are you a man or a woman?
Man, interested in women
Women, interested in men
Man, interested in men
Woman, interested in women
Other  
Required 3.

How old are you?
 

  • 50 characters left.
Required 4.

Would you eventually like to be in a long-term committed relationship or married?
Yes, I would eventually like to be in a long-term relationship.
Yes, I would eventually like to be married.
Yes, I am open to either.
No.
  • Comment:

  • 500 characters left.
Required 5.

Are you currently open to dating?
Yes, I currently go on dates all the time - but nothing serious.
Yes, but I'm not dating right now.
No, I'm not interested in dating.
  • Comment:

  • 500 characters left.
Required 6.

What is your greatest challenge or frustration with single life?
The people I meet are incompatible.
The time/energy I spend at work.
My friends/family don't understand me.
My looks.
My shyness.
I am intimidating to others.
I don't know.
Other  
7.

What do you think prevents you from having the relationship you want?
 

  • 1000 characters left.
Required 8.

What are you currently doing to find a partner?
(Check all that apply.)
I motivate myself go out.
I motivate myself to approach men/women.
I take care of myself physically.
I take care of myself spiritually.
I date online (eHarmony, match.com, etc.).
I use social media (Facebook, Twitter, etc.)
I use a professional matchmaker.
I'm not doing anything different at this time.
Other  
Required 9.

How close do you think you are today to finding a partner?
1 - My reality might be life without a partner. 2 - No prospects right now, but I'm still looking. 3 - We talk, strictly as friends or associates. 4 - There are a few people I'd consider prospects. 5 - If this casual, monogamous relationship would just convert into... 6 - I'm in a long-term relationship but I want more.      
     
  • Comment:

  • 500 characters left.
10.

Do you currently acknowledge a higher power, or something greater than yourself (not necessarily religious or denominational), such as God, Higher Power, Nature, Source, Things as They Truly Are?
Yes
No
I don't know.
Other  
11.

What are your thoughts around the Law of Attraction and/or "The Secret"?
 

  • 350 characters left.
Required 12.

What do you hope improves through your participation in this program?
 

  • 350 characters left.
Required 13.

How did you hear about this program?
"Soulmate from Within" website
Email invitation
"Insight from Within" newsletter
"Soulmate from Within" on BlogTalkRadio
Referral (Please enter your referrer's name in the "Comment" below.)
Other  
Required 14.

What convinced you to apply to this program?
Information on website
Discussion with Friend/Referral
Information on website
Other  
  • Comment:

  • 500 characters left.