Welcome!

Thank you for taking the first step toward healing and reclaiming your life. I understand that breaking free from a narcissistic relationship can feel overwhelming, but you don’t have to go through this alone. This form will help me understand your current situation, challenges, and goals so that we can work together to create a personalized plan for your recovery. Please answer the questions honestly and thoughtfully, knowing that this is a safe space. Your journey toward empowerment and emotional freedom starts here, and I’m here to support you every step of the way.

Contact Information

First Name *

Last Name *

Email *

Phone *

What year were you born? *

Current Situation

Briefly describe your current relationship situation. *

Are you currently in a relationship with a narcissist? *

How long have you been in this relationship?

Challenges

What are the main challenges you are facing in this relationship? *

Have you experienced any of the following? (Select all that apply) *

What additional behaviors are you experiencing (if applicable)?

Readiness to Change

On a scale of 1-10, how ready do you feel to break free from this relationship? *

What has stopped you from leaving or taking steps to protect yourself?

Goals & Expectations

What do you hope to achieve through coaching? *

In what areas are you seeking help for? (Select all that apply) *

What additional ways are you seeking help? (if applicable)

Past Efforts

Have you attempted to leave the relationship in the past?

If yes, what obstacles did you encounter in previous attempts?

Commitment Level

Are you willing to commit to working with a coach to achieve the changes you desire? *

Preferred Coaching Format

What format are you most comfortable with for coaching? *

Any other formats you prefer?

Availability & Time Commitment

What is your preferred time of day for coaching sessions? (Select all that apply) *

Morning

Afternoon

Evening

How much time per week can you commit to working on your recovery?

Additional Information

Is there anything else you'd like to share that would help me get to know your situation a little better before we meet?

Consent

Do you agree to the Terms & Conditions and the Privacy Policy of the coaching services provided by The 12 Promises? (review the links below) *

I consent

Opt-In

I consent to receive communications and understand I can opt-out at anytime.