Intake Questionnaire Your journey to intentional love starts here.Please complete the following information honestly. All answers are confidential and used solely to help us find the most compatible matches for you. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 14Full Name *FirstLastDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender Identity *--- Select Choice ---MaleFemaleOtherSexual Orientation *--- Select Choice ---HeterosexualLGBTQ+OtherRelationship Status: *--- Select Choice ---SingleDivorcedWidowedNextChildren *YesNoIf yes, how many and ages?PreviousNextLocation (City & State): *Willing to relocate for the right person? *--- Select Choice ---YesNoMaybePreviousNextContact InfoPhone NumberEmail *Preferred method of communication: *CallTextEmailPreviousNextProfession/Occupation: *Level of Education: *Annual Income Range: *Under $100K$100K–$250K$250K+Work Schedule: *Travel Frequency: *RarelyOccasionallyOftenDo you work remotely? *YesNoPreviousNext looking mixers, & Hobbies or interests: *Health & Wellness habits (gym, diet, etc.): *Religious or spiritual beliefs: *Political Views: *ConservativeModerateLiberalPrefer not to sayPreviousNextDating PreferencesAge range of ideal partner: Selected Value: 25 Height preference:no preferenceNo preferenceMinimum:MaximumEthnicity preference (if any)PreviousNextDo you want children in the future? *YesNoMaybeDealbreakers (smoking, religion, distance, etc.): *What qualities are you seeking in a partner? *What values are most important to you in a relationship? *PreviousNextHave you been in love before? *YesNoWhat has held you back from finding love until now? *Are you open to dating outside your culture/background? *YesNoPreviousNextCoaching & Readiness Have you ever worked with a coach or therapist? *YesNoAre you open to 1:1 coaching to improve your dating skills or confidence? *YesNoOn a scale from 1–10, how coachable are you? Selected Value: 5 Do you believe love requires effort and intentionality? *YesNoPreviousNextWhat are your biggest struggles in dating right now? *Are you ready to invest time and energy into finding your person? *YesNoPreviousNextEvents & Social DynamicsWould you attend exclusive singles events or retreats? *YesNoAre you open to participating in dating dynamics (e.g., mixers, panel games, curated challenges)? *YesNoHow would you describe your social personality? *--- Select Choice ---IntrovertAmbivertExtrovertPreviousNextFinal Thoughts What would make this experience successful for you?Anything else you want us to know?Why is now the right time for love in your life? How soon are you looking to meet the right person? *ImmediatelyWithin 3 months6 months+How long have you been single? *PreviousNextAre you interested in learning more about? (Check all that apply)Image Consultation & Personal StylingHair & Makeover TransformationDating Skills & Confidence CoachingExclusive Singles EventsSpeaking Engagements & Personal Development WorkshopsSubmit
