3-Day Virtual Romance Recovery Retreat
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New Client Questionnaire
How are you feeling today?
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PST Pacific Standard Time (North America) UTC−08
MDT Mountain Daylight Time (North America) UTC−06
CST Central Standard Time (North America) UTC−06
EST Eastern Standard Time (North America) UTC−05
ACDT Australian Central Daylight Savings Time UTC+10:30
ACST Australian Central Standard Time UTC+09:30
ACT Acre Time UTC−05
ACT ASEAN Common Time (unofficial) UTC+06:30 – UTC+09
ACWST Australian Central Western Standard Time (unofficial) UTC+08:45
ADT Atlantic Daylight Time UTC−03
AEDT Australian Eastern Daylight Savings Time UTC+11
AEST Australian Eastern Standard Time UTC+10
AFT Afghanistan Time UTC+04:30
AKDT Alaska Daylight Time UTC−08
AKST Alaska Standard Time UTC−09
ALMT Alma-Ata Time[1] UTC+06
AMST Amazon Summer Time (Brazil)[2] UTC−03
AMT Amazon Time (Brazil)[3] UTC−04
AMT Armenia Time UTC+04
ANAT Anadyr Time[4] UTC+12
AQTT Aqtobe Time[5] UTC+05
ART Argentina Time UTC−03
AST Arabia Standard Time UTC+03
AST Atlantic Standard Time UTC−04
AWST Australian Western Standard Time UTC+08
AZOST Azores Summer Time UTC±00
AZOT Azores Standard Time UTC−01
AZT Azerbaijan Time UTC+04
BDT Brunei Time UTC+08
BIOT British Indian Ocean Time UTC+06
BIT Baker Island Time UTC−12
BOT Bolivia Time UTC−04
BRST BrasÃlia Summer Time UTC−02
BRT BrasÃlia Time UTC−03
BST Bangladesh Standard Time UTC+06
BST Bougainville Standard Time[6] UTC+11
BST British Summer Time (British Standard Time from Feb 1968 to Oct 1971) UTC+01
BTT Bhutan Time UTC+06
CAT Central Africa Time UTC+02
CCT Cocos Islands Time UTC+06:30
CDT Central Daylight Time (North America) UTC−05
CDT Cuba Daylight Time[7] UTC−04
CEST Central European Summer Time (Cf. HAEC) UTC+02
CET Central European Time UTC+01
CHADT Chatham Daylight Time UTC+13:45
CHAST Chatham Standard Time UTC+12:45
CHOT Choibalsan Standard Time UTC+08
CHOST Choibalsan Summer Time UTC+09
CHST Chamorro Standard Time UTC+10
CHUT Chuuk Time UTC+10
CIST Clipperton Island Standard Time UTC−08
CIT Central Indonesia Time UTC+08
CKT Cook Island Time UTC−10
CLST Chile Summer Time UTC−03
CLT Chile Standard Time UTC−04
COST Colombia Summer Time UTC−04
COT Colombia Time UTC−05
CST China Standard Time UTC+08
CST Cuba Standard Time UTC−05
CT China Time UTC+08
CVT Cape Verde Time UTC−01
CWST Central Western Standard Time (Australia) unofficial UTC+08:45
CXT Christmas Island Time UTC+07
DAVT Davis Time UTC+07
DDUT Dumont d'Urville Time UTC+10
DFT AIX-specific equivalent of Central European Time[NB 1] UTC+01
EASST Easter Island Summer Time UTC−05
EAST Easter Island Standard Time UTC−06
EAT East Africa Time UTC+03
ECT Eastern Caribbean Time (does not recognise DST) UTC−04
ECT Ecuador Time UTC−05
EDT Eastern Daylight Time (North America) UTC−04
EEST Eastern European Summer Time UTC+03
EET Eastern European Time UTC+02
EGST Eastern Greenland Summer Time UTC±00
EGT Eastern Greenland Time UTC−01
EIT Eastern Indonesian Time UTC+09
FET Further-eastern European Time UTC+03
FJT Fiji Time UTC+12
FKST Falkland Islands Summer Time UTC−03
FKT Falkland Islands Time UTC−04
FNT Fernando de Noronha Time UTC−02
GALT Galápagos Time UTC−06
GAMT Gambier Islands Time UTC−09
GET Georgia Standard Time UTC+04
GFT French Guiana Time UTC−03
GILT Gilbert Island Time UTC+12
GIT Gambier Island Time UTC−09
GMT Greenwich Mean Time UTC±00
GST South Georgia and the South Sandwich Islands Time UTC−02
GST Gulf Standard Time UTC+04
GYT Guyana Time UTC−04
HDT Hawaii–Aleutian Daylight Time UTC−09
HAEC Heure Avancée d'Europe Centrale French-language name for CEST UTC+02
HST Hawaii–Aleutian Standard Time UTC−10
HKT Hong Kong Time UTC+08
HMT Heard and McDonald Islands Time UTC+05
HOVST Hovd Summer Time (not used from 2017-present) UTC+08
HOVT Hovd Time UTC+07
ICT Indochina Time UTC+07
IDLW International Day Line West time zone UTC−12
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IRKT Irkutsk Time UTC+08
IRST Iran Standard Time UTC+03:30
IST Indian Standard Time UTC+05:30
IST Irish Standard Time[8] UTC+01
IST Israel Standard Time UTC+02
JST Japan Standard Time UTC+09
KALT Kaliningrad Time UTC+02
KGT Kyrgyzstan Time UTC+06
KOST Kosrae Time UTC+11
KRAT Krasnoyarsk Time UTC+07
KST Korea Standard Time UTC+09
LHST Lord Howe Standard Time UTC+10:30
LHST Lord Howe Summer Time UTC+11
LINT Line Islands Time UTC+14
MAGT Magadan Time UTC+12
MART Marquesas Islands Time UTC−09:30
MAWT Mawson Station Time UTC+05
MET Middle European Time Same zone as CET UTC+01
MEST Middle European Summer Time Same zone as CEST UTC+02
MHT Marshall Islands Time UTC+12
MIST Macquarie Island Station Time UTC+11
MIT Marquesas Islands Time UTC−09:30
MMT Myanmar Standard Time UTC+06:30
MSK Moscow Time UTC+03
MST Malaysia Standard Time UTC+08
MST Mountain Standard Time (North America) UTC−07
MUT Mauritius Time UTC+04
MVT Maldives Time UTC+05
MYT Malaysia Time UTC+08
NCT New Caledonia Time UTC+11
NDT Newfoundland Daylight Time UTC−02:30
NFT Norfolk Island Time UTC+11
NOVT Novosibirsk Time [9] UTC+07
NPT Nepal Time UTC+05:45
NST Newfoundland Standard Time UTC−03:30
NT Newfoundland Time UTC−03:30
NUT Niue Time UTC−11
NZDT New Zealand Daylight Time UTC+13
NZST New Zealand Standard Time UTC+12
OMST Omsk Time UTC+06
ORAT Oral Time UTC+05
PDT Pacific Daylight Time (North America) UTC−07
PET Peru Time UTC−05
PETT Kamchatka Time UTC+12
PGT Papua New Guinea Time UTC+10
PHOT Phoenix Island Time UTC+13
PHT Philippine Time UTC+08
PKT Pakistan Standard Time UTC+05
PMDT Saint Pierre and Miquelon Daylight Time UTC−02
PMST Saint Pierre and Miquelon Standard Time UTC−03
PONT Pohnpei Standard Time UTC+11
PST Philippine Standard Time UTC+08
PYST Paraguay Summer Time[10] UTC−03
PYT Paraguay Time[11] UTC−04
RET Réunion Time UTC+04
ROTT Rothera Research Station Time UTC−03
SAKT Sakhalin Island Time UTC+11
SAMT Samara Time UTC+04
SAST South African Standard Time UTC+02
SBT Solomon Islands Time UTC+11
SCT Seychelles Time UTC+04
SDT Samoa Daylight Time UTC−10
SGT Singapore Time UTC+08
SLST Sri Lanka Standard Time UTC+05:30
SRET Srednekolymsk Time UTC+11
SRT Suriname Time UTC−03
SST Samoa Standard Time UTC−11
SST Singapore Standard Time UTC+08
SYOT Showa Station Time UTC+03
TAHT Tahiti Time UTC−10
THA Thailand Standard Time UTC+07
TFT French Southern and Antarctic Time[12] UTC+05
TJT Tajikistan Time UTC+05
TKT Tokelau Time UTC+13
TLT Timor Leste Time UTC+09
TMT Turkmenistan Time UTC+05
TRT Turkey Time UTC+03
TOT Tonga Time UTC+13
TVT Tuvalu Time UTC+12
ULAST Ulaanbaatar Summer Time UTC+09
ULAT Ulaanbaatar Standard Time UTC+08
UTC Coordinated Universal Time UTC±00
UYST Uruguay Summer Time UTC−02
UYT Uruguay Standard Time UTC−03
UZT Uzbekistan Time UTC+05
VET Venezuelan Standard Time UTC−04
VLAT Vladivostok Time UTC+10
VOLT Volgograd Time UTC+04
VOST Vostok Station Time UTC+06
VUT Vanuatu Time UTC+11
WAKT Wake Island Time UTC+12
WAST West Africa Summer Time UTC+02
WAT West Africa Time UTC+01
WEST Western European Summer Time UTC+01
WET Western European Time UTC±00
WIT Western Indonesian Time UTC+07
WST Western Standard Time UTC+08
YAKT Yakutsk Time UTC+09
YEKT Yekaterinburg Time UTC+05
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What are you seeking help with? What's the problem you are facing?
Has something happened to help you make your decision to get counseling now? Please share.
Select All Conditions You've Had Issue With
Anxiety
Depression
Anger
Concentration
Phobia
Communication
Drugs/Alcohol
Eating Disorder
Parents
Children
Sleeping
Child Abuse
Sex Abuse
Nightmare
Financial Problem
Head Injuries
Nausea
Attention
Trusting Others
Worry
Self-Inflicted Pain
Can't keep a job
STD
Neck Pain
Diabetics
High Blood Pressure
Obesity
Suicidal Thoughts/Attempts
Marital Status
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Married
Dating/Engaged
Living Together
Not in a relationship
Answer if you are married, living together, engaged or dating
Partner Name
Please provide partner information if in a marital relationship
Partner Email
Please provide partner information if in a marital relationship
Confirm Partner Email
Confirm email here
Marriage Anniversary Date
Is your marriage/relationship in serious trouble?
Yes
No
Are you considering breaking up?
Are both of you committed to getting help for your marriage?
Yes
No
What is your spiritual orientation?
Standard Non Faith-Specific
Catholic Christian
Protestant or Non-Denominational Christian
Orthodox Christian
Jewish
If you are a couple this is needed for your relationship assessment.
Let us know how you found us
How did you hear about us?
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Why did you pick us?
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Where did you get our number to make this call?
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Google Search
Other Search Engine
Psychology Today
Good Therapy
Lifestyle Website
Sizzling Hot Marriage Website
A friend
Other Source
Other source
Share what other search engine, friend or other source for this referral
What was your search term?
What words did you use to search on?
Are you just now looking for a therapist or did you start looking a while back and just decided it was time to get help?
Just started looking
Started looking a while back
How long ago did you first start looking?
Have you been to our website at LifestyleTherapyCoach.com?
Yes
No
Are you thinking about hurting yourself or someone else?
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Yes
No
If you are thinking of hurting yourself or someone else you should call 911 and let them know so that you can get assistance right away.
Are you looking for us to prescribe medicine for you?
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Yes
No
We don't prescribe medicine.
We do not offer in-person sessions. Are you OK with video conferencing?
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Yes
No
We have found that video conferencing is just as effective as face-to-face. We utilize Zoom primarily.
Are you ready to do something different?
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Very Ready
Mostly Ready
Not Ready
Just making sure you are a serious client in a position to put your all into this process.
Are you prepared to spend the time needed to work on your goals?
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Very Prepared
Mostly Prepared
Not Prepared
Do you have time for this in your weekly routine and are you willing to focus on this for extended amount of time?
Are you prepared to cover the cost of these services?
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Very Prepared
Mostly Prepared
Not Prepared
One must consider what resources they have available to invest in therapy and coaching
Who do you watch or listen to about relationships? Which platforms do you listen to them?
If you are human, leave this field blank.
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