Application form-R

For your “Find-Your-Path-Towards-Authentic-And-Loving-Relationships-Consultancy”
goals:
-overcoming inner conflicts,
-overcoming struggles within your relationships like family, friends, collegues.
-overcoming emotionally abusive and neglective traumatic relationships,
-finding inner peace
-having great relationships and a great social life

Copy the questions to your word processor. Answer all questions and send per email to Freyajoy@loveempowermentcenter.com.

1. Name:

2. Family name:

3. Emailadress:

4. Phone number:

5. City:

6. Country/state:

7. Birth date and birthplace:

8. How did you find me?
O General Practitioner
O someone I know, if yes, would you like to share with me who was it? ……….
O google, if yes, what keywords did you use: ……………….
O Koorddanser
O Djoj
O Mens en Relaties
O Article in magazine: please specify: ………………
O Testimonial of a client
O Online forum
O Elswehere: please specify …………………….

9. What is your complaint or question?

10. How long are you struggling with this issue?

11. What are your biggest fears and frustrations in the area of your relationship struggles?

12. Have you taken action already to solve your problems and if yes, what were the results?

13. What is your vision for your relationships? How would you like your social life to look like after 6 or 12 months from now, if things would go really really well?

14. If you still would have this problem a year from now, what would that mean to you?

15. Why is it important for you to overcome your struggles in your relationships right now?

16. How determined are you to handle this problem right now? Give a number between 1 and 10. (1 means: This has no priority for me right now, 10 means I am committed to solve this for once and for all, and it is my first priority).

17. On a scale between 1 and 10: how important is it for you to overcome this problem now
within 12 months? (1 means “not important”, 10 means “extremely important”)

18. Are there other problems that you want to work at as well? If yes, what are these other problems?

19. Have you been in psychotherapy prior to this application? If yes, for what? And what was the result?

20. Have you ever received other training or coaching for your personal development? If yes, what kind of training/coaching? For what did you receive it? What were the results?

21. Have you ever been admitted to a psychiatric hospital? If yes, when was that, what was the diagnosis and what were the results for you?

22. Do you drink alcohol? If yes, how many days in a month? And how many glasses on a day (maximum)?

23. Do you use drugs? If yes, what drugs, and how often do you use it?

24. Have you ever had delusions or hallucinations?

25. Have you ever committed a suicide attempt? If yes when was that?

26. Are there things that you are extremely afraid for (phobic)? If yes, for what?

27. Do you have an obcessive compulsive disorder or an eating disorder?

28. Do you prefer to have this consultancy one on one, or do you want to bring your partner?

29. Which parts of the day suit you to make an appointment?

30. Do you prefer to have this consultancy at location in Amsterdam, or by phone, or with Zoom (a video calling program that you can download easily. The free version will do. (https://zoom.us/)

Thank you for answering all of the questions. Email the filled in application form to freyajoy@loveempowermentcenter.com. After receiving your application FreyaJoy will connect with you soon to make an appointment.

Nota Bene: if you didn’t receive an answer within 48 business hours, check your spamfolder)

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