Intake form

Name *

Email address *

What is your current relationship status?

What challenges have you faced in your relationships?

Please select at least one option.

Divorce

Loss of a partner

Prolonged singleness

Emotional trauma

Trust issues

Fear of commitment

How did you hear about CSM: the sanctuary for renewed beginnings?

What are your personal goals for joining this program?

What areas of your life do you seek to improve?

Please select at least one option.

Spiritual growth

Emotional healing

Relationship skills

Self-esteem

Life purpose

Networking with others

Are you willing to participate in group sessions?

What is your preferred method of communication?

Please select at least one option.

Email

Phone

In-person

Video call

Do you have any specific topics you would like to discuss during sessions?

Additional questions or comments

CSM: THE SANCTUARY FOR RENEWED BEGINNINGS