Breakup to Breakthrough Workshop Pre-Survey

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Participant Survey

This workshop is for those serious about recovering from a breakup and moving on with their lives. This survey will help me prepare for you and ensure you have the best experience possible. It should only take a couple of minutes to complete. Upon completion, you’ll receive the meeting login information.

Breakup to Breakthrough Workshop Pre-Survey

First Name * First Last Name * Last Email * Phone

Are you currently in a serious relationship? *

Yes

Your most recent breakup was: *

Within the last month

Within the last year

Many months/years ago

I've not been through a breakup

What were the symptoms you experienced following your breakup? *

Extreme sadness and depression

Loss of appetite and weight changes

Insomnia or difficulty sleeping

Decreased interest in once enjoyable activities

Anxiety and restlessness

Persistent feelings of anger or bitterness toward the other person

Dwelling on the past and constantly thinking about the breakup

Low self-esteem and negative self-talk

Difficulty trusting others in future relationships

Social isolation and withdrawal from family and friends

100 being the most severe, place the slider in a position that reflects how severe your symptoms are today. *

Will you be on camera and engaged the entire workshop? *

Yes

Will you remove all distractions and make sure your face is well lit during the workshop? *

Yes

Are you ready to invest time and money in your personal development? *

Yes

Are you available to schedule a free follow-up clarity call with Joe to discuss your goals? *

Yes

If you are human, leave this field blank.

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