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YOUR LASTING LOVE NEEDS ASSESSMENT

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Question 1 of 15

PERSONAL INFORMATION AND INTERESTS. 

In order to serve your present and future needs, please provide your:

 

1. NAME

2. EMAIL

3. PHONE

4. ADDRESS

5. GENDER

6. AGE and BIRTHDAY

7. FAVORITE FOODS

8. HOBBIES

9. PETS

Question 2 of 15

HEALTH PROFILE

Please indicate ANY current challenges, including:

1. EMOTIONAL (such as depression, anxiety, PTSD, OCD, bi-polar disorder, personality disorders, eating disorders, addictions, suicidal thoughts, etc.)

2. PHYSICAL OR MEDICAL (diabetes, heart conditions, obesity, etc.). 

3. FOOD OR ALLERGY RESTRICTIONS

 

Question 3 of 15

RELATIONSHIP HISTORY

Please share with us:

 

1. YOUR RELATIONSHIP STATUS (never married, engaged, divorced, separated, widowed, and HOW MANY TIMES you've been engaged or married)

 

2. THE GENDER and AGES of your CHILDREN

 

3. A brief description of your PREVIOUS RELATIONSHIPS and/or MARRIAGES and HOW LONG each lasted

 

4. YOUR BEST GUESS about what happened in these relationships and your role in the problems you experienced

 

5. A brief description of your MOST SERIOUS RELATIONSHIP 

 

6. A brief description OF your most SERIOUS relationship in THE LAST THREE YEARS

Question 4 of 15

CURRENT DATING AND RELATIONSHIP SITUATION

(Select all that apply)
A

Not dating at all

B

Dating but not often

C

Dating but not exclusively

D

Being Under appreciated (in a "just friends", "too nice", "hanging out", or "good-for-now" situation

E

Being abused, manipulated, cheated on, or suffering from their addictive behaviors

F

Feeling less passion or commitment for my partner

G

Feeling less passion and commitment from my partner

H

In a relationship that I want to make great!

Question 5 of 15

MORE RELATIONSHIP DETAILS

Please share with us:

 

1. How many DATES you have been on in the last YEAR (i.e. under 5, over 10, over 50).

 

2. WHAT RESOURCES you have used to help you date or build relationships (books, dating apps, online dating, coaching, singles cruises, singles conferences, matchmaking, counseling, church groups, bars, blind dates, meet up groups, social media, etc.) --AND-- HOW DID THESE RESOURCES HELP YOU

Question 6 of 15

PERSONAL AND FAMILY HISTORY

Please share with us:

 

1. Whether your PARENTS are divorce, married, or widowed

 

2. How you saw your PARENT'S RELATIONSHIP when you were a CHILD and how you see it now as an ADULT

 

3. How many SIBLINGS you have and where you fit in the family 

 

4. Any CHILDHOOD TRAUMAS (physical, sexual, or emotional abuse, illnesses, delayed speech, walking, or significant hospitalizations) you experienced

 

5. Any EDUCATIONAL STRUGGLES (ADD, learning challenges, etc.) or advancements, social challenges (shyness, bullying, etc.) you experienced as a child

 

6. Any EMOTIONAL CHALLENGES (depression, anxiety, OCD, suicidal thoughts, eating disorders) you experienced as a child

 

7. Any ADULTHOOD TRAUMAS (physical, sexual, or emotional abuse, illnesses, significant injuries, or hospitalizations) you've experienced and your age at the time of the incident  

 

8. Any counseling, education, or professional services you have engaged to help you resolve the issues described above.

 

9. If you know your Myers-Briggs 16 Personality Profile or Personality Color (red, blue, yellow, white).

Question 7 of 15

EDUCATION AND EMPLOYMENT HISTORY

Please share with us:

 

1. Your EDUCATIONAL history and/or DEGREES

 

2. A brief description of your EMPLOYMENT history or professional CAREER

Question 8 of 15

CONCERNS AND NEEDS

Which of the following are of the GREATEST PRIORITY to you

(Select all that apply)
A

Finding desirable singles

B

Safety and security (physically, emotionally, or financially)

C

Common interests and hobbies

D

Attraction

E

Compatibility

F

Passion and chemistry

G

Communication skills

H

Creating a secure attachment

I

Problem solving skills

J

Step-parenting concerns

K

Commitment

L

Marriage

M

Education

N

Career

Question 9 of 15

FEARS AND MORE

Please share with us:

 

1. Of the CONCERNS and NEEDS listed previous, are there more you would add?

 

2. What FEARS do you have about dating or getting into a relationship or marriage?

 

3. Is there anything else you think WE SHOULD KNOW?

Question 10 of 15

WHY NOW?

Please share with us:

 

1. What made you decide that NOW IS THE TIME to CREATE LASTING LOVE

 

2. What you would HOPE to ACHIEVE from WORKING WITH US

 

Question 11 of 15

RELATIVE TO OUR SERVICES

Please share with us:

 

1. How you LEARNED ABOUT our services (internet search, referral, podcast, public speaking, social media, etc.)?

 

2. If a previous or current CLIENT REFERRED you, please share WHO THEY ARE SO WE CAN THANK THEM. 

Question 12 of 15

PREFERENCES

Which of the products and services below have the GREATEST value to you?

(Select all that apply)
A

Access to the LASTING LOVE ACADEMY LIBRARY with hard-copy books and audios/videos that are mobile friendly

B

PERSONALIZED advice and strategies with goal setting, feedback, accountability, and support

C

FACE-TO-FACE appointments

D

PHONE calls

E

VIDEO calls (Facetime, Zoom, etc.)

Question 13 of 15

READINESS ASSESSMENT

Which of the following BEST DESCRIBES YOU:

(Select all that apply)
A

I want to talk, but I'm not ready to commit

B

I want to talk and am hopeful you can help me

C

I'm ready for transformative online materials, including audios, videos, and books for creating LASTING LOVE

D

I'm ready to engage in LOVE and LIFE CHANGING strategies and services

E

I'm ALL-IN and committed to doing whatever it takes to make lasting love happen for me this year!

Question 14 of 15

PRIORITIES

When considering products or services, which of the following are of the GREATEST PRIORITY TO YOU:

(Select all that apply)
A

Cost

B

Value

C

Benefits

Question 15 of 15

FOR FUN

On a personal note, will you please share with us:

 

1. Your favorite drink, type of food, restaurant, snack, and/or desert

 

2. Your favorite movie genre, hero or mentor, type of music

 

3. Your favorite activity, sport, or relaxing past time

 

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