Intake After Payment - #1 Marriage Boot Camp Seminar

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Boot Camp Registration - Intake

Welcome to the Marriage and Life Enrichment Boot Camp event!

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Preparing for our upcoming meeting we would love to know a bit more about you. Please fill the form below TODAY!

Intake Form

Step 1 of 5

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Name*
Relationship Status*
Birth date*
MM slash DD slash YYYY

On a scale of 1-10 rate the following based on how you felt as a child
My life*
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My primary relationship*
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My relationship with my mother*
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My relationship with my father*
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My work life*
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My health*
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My finances*
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Check any types of help have you received*
- Therapy
- Counseling
- Self-Help
- 12-Step
- Seminars
- Other
Other

Answer the following questions based on how you felt as a child
My feelings are OK*
- Yes
- No
It's OK to be vulnerable*
- Yes
- No
It's OK to express my needs*
- Yes
- No
My care givers were consistent and predictable*
- Yes
- No

Fill in the blanks
If I could get one thing out of my Boot Camp experience it would be*
My perfect world has the following characteristics*

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Email*
Spouse Name*
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