Self Assessment Form Coaching Assessment Name: * Email: * Age: * Phone: * Preferred Contact: * Email Phone Text Preferred days for coaching: * Weekdays Weekends Preferred time for coaching: * Mornings Midday Afternoons THIS INFORMATION WILL BE KEPT PRIVATE AND SECURE. IT WILL BE USED TO HELP US DETERMINE IF THE DATEWISE COACHING IS THE RIGHT FIT FOR YOU. WE WILL DISCUSS THIS IN MORE DETAIL IN OUR INITIAL 45-MINUTE PHONE CONVERSATION. THANK YOU! Note: The term “caregiver” is used instead of parent, because you might have been raised by someone other than a parent (an aunt, grandmother, or older sibling, etc.). 1. As a child, my most significant relationship with an adult was with this person: * He or she was important to me because: * 2. Which of the following describe your relationship with your caregivers? * (check all that apply) My caregivers were “checked out” or preoccupied and my emotional needs went unmet. My caregivers were not around most of the time, so my physical needs went unmet. I only got attention when I did something really good or really bad. If I showed I wanted love and attention, it meant I was being weak or needy. I felt like I had to be the caregiver, and I took care of them. I often felt ashamed of my behavior or I was punished for being a “bad” kid. I felt like anxious and unsettled around my parents, because I wasn’t sure what to expect from them. If I didn’t please them, follow the rules or generally succeed, my caregivers would be angry or disappointed. When I did something bad, my caregivers recognized it was a mistake and never made me feel like I was a bad person for making the mistake. 3. Describe how your caregivers responded in the following scenarios: If I expressed a negative emotion that showed as anxiety, worry, anger, irritation, blaming, defiance, or demanding, my caregivers responded by: * If I expressed sadness, disappointment, or embarrassment, my caregivers responded by: * If I ever expressed what I was feeling by giving the silent treatment or clamming up, my caregivers responded by: * If I expressed joy and happiness, my caregivers responded by: * 4. Which of the following patterns describe your past romantic relationships? * (check all that apply) I became overly accommodating and denied my own needs. I tended to lose touch with my friends and family. I felt anxious when I was not in constant contact with him. I stayed single for long periods of time because it was easier to be alone. My relationships started out strong, but often ended abruptly. I often felt unloved in the relationships. I usually felt like it was my fault when the relationships ended. I’ve been attracted to men who played hard to get, kept me at arms-length, or were generally unavailable (lived in another city, worked all the time, were married, etc.) I’ve avoided relationships and put a lot of energy into my pets, work, volunteering, exercise, shopping, alcohol, or drugs. I tended to withdraw when my partner (or friends) would try to get too close to me. My relationships started out great at first, but then I would get tired of my partner. I often broke promises or disappointed my partner. Sometimes I would fabricate excuses to cover up my behavior or hide the truth. I got frustrated that he didn’t pick up on cues about how I wanted to be treated, wanted him to react, etc. I’ve been the outgoing one in my relationships, while my partners were always the quiet, more introverted ones. I felt suffocated or confined by the relationship. I focused on taking care of my partner’s needs but I would resent it and later be angry about it. I would boss my partner around. Sometimes I would tease and belittle my partner in front of others. I often wondered what he was thinking and I where our relationship was headed. I couldn’t tolerate when my partner would make mistakes. Sometimes I would show my partner affection and love, and then I’d pull away. I would pull away if my partner acted too needy. My partner was usually more to blame than I was when things weren’t going well. I would use my charm and sexuality to win him over, then I’d lose interest when he started to like me. Other 5. In my past relationships, I experienced physical, mental, or verbal abuse: * Yes No If yes, this is what happened: 6. I’ve experienced depression and/or anxiety: * Yes No If yes, this was my experience: * 7. I have children in my life: * Yes No If yes, their ages are: They are with me this often: 8. Which of the following have you tried for the purpose of improving your love life? * (check all that apply) Magazine or online articles, etc. Self-help books Workshops and retreats Coaching Therapy or counseling Astrology, horoscopes, tarot cards, etc. Other The strategies I tried helped me improve my love life in these ways: * 9. My perfect relationship looks like: * (check all that apply) We are soulmates. We have different interests. We each have our own friends. He looks exactly as I’ve always imagined and dreamed he would look. We do almost everything together. He makes me feel whole and completely satisfied. We have friends that we share. We knew the minute we met that we were ideal for each other. We share the same interests. We never fight. We are both comfortable because it feels similar to past relationships. We share the same fundamental values about life. 10. I would describe the current people in my life who support me as follows: * 11. Even though my support network is great, they could not or would not be able to help me with these types of things in my life: * 12. On a scale of 1 to 10, with 10 being the highest, how would you rate yourself on the following? My commitment to doing the work to find a long-term love relationship: * 1 2 3 4 5 6 7 8 9 10 My commitment to following a program, including completing self-exploration exercises: * 1 2 3 4 5 6 7 8 9 10 13. If I met my ideal partner, my life would change in many ways, including: * 14. Which of the following statements describe you? (check all that apply) * I am open-minded and willing to try dating a new way with the goal of finding a long-term relationship. I see value in completing self-exploration exercises. I want straightforward, easy-to-follow guidance with specific action items. I know I deserve love, even if I did not receive the love and nurturing I needed in the past. I am willing to learn and practice open and honest communication with others. I am willing to establish and communicate my personal boundaries. I accept myself and love myself (or at least like myself a lot). I am willing to recognize positive and negative patterns and behaviors in myself and in my relationships with others. If I get stuck in an area that is beyond the scope of the DateWise program, I am willing to seek outside professional therapy or counseling. 15. My biggest fears about dating and finding love include: * 16. Questions or concerns I have about working with a dating coach: * Post navigation
