Saving Relationships Workshop

Confidential Questionnaire.

Part1 General

Please select the course for which you are filling out this form.

  1. Understanding Biotic Space ($50.00)
  2. Biotic Space Exercises ($100.00)
  3. Saving my Relationship ($249.00)

Name 1

Name 2


E-mail address:

Address (optional):

Your phone number (optional):

Date of birth 1

Date of birth 2

Are you under professional care?

  1. yes
  2. no

Are you taking prescribed medication?

  1. yes
  2. no

Are you afraid of being left alone?

  1. no
  2. mildly
  3. strongly

Can you spend time by yourself?

  1. yes
  2. prefer
  3. rather not

Self-assessment attributes (mark applicable items)

  1. spiritual
  2. religious
  3. artistic
  4. altruist
  5. giver
  6. taker
  7. compromiser
  8. leader
  9. follower
  10. teacher
  11. practical
  12. forgiving
  13. private
  14. secretive
  15. dependable
  16. generous
  17. critical
  18. outgoing
  19. calm
  20. superstitious .

Please follow a scale of 1 to 10 (1 is low . . . 10 is extremely high) to rate yourself for the following items.

Your sense of aggression:

Your sense of stress:

Your sense of commitment:

Your sense of confidence:

Your sense of physical health:

Your sense of spiritual health:

Your sense of balance:

openness to new concepts:

On the same scale, show how well you can concentrate on learning a new concept:

Once you start on a project, continuity is important. Can you commit half hour per day for your happiness?

  1. yes
  2. no

Please mark ONE concept you feel at home naturally

  1. Mountain
  2. Stream
  3. Tree
  4. Unity
  5. Duality

What do you seek from a relationship? relationship.

If something else, please explain, Explanation:

Do you understand the concept of feminine nature of spirituality?

  1. yes
  2. no

Do you understand the concept of Karma?

  1. yes
  2. no

Of the relationships based on gender, which ones you consider as more compatible?

  1. male/male
  2. female/male
  3. female/female
  4. mother/daughter
  5. mother/son
  6. father/daughter
  7. father/son
  8. brother/sister
  9. brother/brother
  10. sister/sister
  11. mother/father .

During childhood who did you feel close to?

  1. mother
  2. father
  3. teacher
  4. brother
  5. sister

Add a comment re above Childhood comment: ***************************

I confirm that I am providing this self-assessment, because this relationship is very important to me

Please state what you would like to achieve for yourself.

Your goal:

Be proud that you have taken the first step!

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