Single But Ready - Application

Xclusive Encounters Application

Fields marked with * are required

Name *

Email *

Address

Address 2

City *

State *

Zip

Home Phone

Cell Phone *

Age *

Do you use text messaging?

Yes

Skype ID?

Marital Status *

Single

Married

Separated

Widowed

How Long

Preliminary Assessment Questions

Please answer briefly and honestly:

Why are you currently single? *

If you are divorced, what caused the divorce? *

Are you casually dating? *

When was your last serious relationship? How long did it last? *

Why are you interested in attending Xclusive Encounters? *

Are you currently seeing a counselor, therapist, or other mental health professional? *

Yes

If "Yes" Would you be willing to sign a release allowing your life coach to consult with them?

Yes

Are you ready and willing to invest in and cooperate with a coach, make appropriate changes in your life, and be accountable to your coach in goal setting and thinking/behavior changes? *

Yes

Please make any additional comments here:

Electronic Signature *

By typing your name in the box above, you are acknowledging that the information provided is true and correct to the best of your knowledge and that you request evaluation for Relationship Readiness Coaching with Single But ready an affiliate of Marpe' Youth & Family Services, Inc.