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RE-PAIR

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Join
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New Members Audit Dock

Audit Dock

Help us to get to know you

Hi there, this is where we begin to build your personal coaching. All of your information is held in the strictest of confidence so you can relax and let us know what’s really going on.

The form uses easy Check boxes, Drop-down Menus and Sliders that allow you to do a full Audit of where you are right now. The more information your Coach has in your first Coaching Session, the faster they can help.

My Real Name *

First

Last

My Avatar Name / User Name (The name I will use on the Re-Pair site) *

Email *

What kind of Personal or Romantic Relationship are you in? *

What type of Relationship would you like help with? *

From 1 - 10, How much STRESS does this relationship give you?

Selected Value: 1

From 1 to 10, How COMMITTED are you to fixing this Relationship?

Selected Value: 1

From 0 - 10, How committed is the OTHER PERSON to fixing this Relationship?

Selected Value: 0

Does the other person recognise that there is a problem?

I don't know
Yes, and they want to fix it too
Yes, but they think it's my fault
Yes, but they are not prepared to do anything about it
Yes, they say that they'll fix it but they never do
Yes, but they think it's not fixable
No, they don't see the problem
No, they just think I'm complaining
No, they think this is normal and all relationships have problems
Other

If you checked 'Other' please clarify...

1. Tell us a little bit about the relationship that you’d like to work on *

How do you like to reference your gender? *

How do you like to reference your sexuality

How would you rate your self-confidence?

Selected Value: 0

Do you Believe that it's possible to bring your Confidence level to 100%? *

Yes
No
Maybe

Can you name 3 things that would bring your Confidence level closer to 100%? *

What is your current Living Arrangment?

From 0 - 10... How Happy are you where you live?

Selected Value: 0

Do you get on with all of the people that you live with?

Yes, mostly
No, not at all
There is just one person who make my life difficult
There are a few people that makes my life difficult
I genuinely love the people I live with
I actually hate the people I live with

Have you ever lived completely alone? *

Yes
No

From 1 - 10 How Happy or Comfortable would you be if you lived alone?

Selected Value: 0

Does your life contain many arguments? *

Yes
No
Just the normal amount

What is your argument style? *

Has anything traumatic happened to you in your past? *

Do you think that this traumatic event still affects you? *

Yes
No

How do you think this event has changed you, or affected you?

From 0 - 10 How Sad or Happy have you been feeling?

Selected Value: 0

From 0 - 10 How good are you at explaining your feelings to others?

Selected Value: 0

Are there exceptions to this?

Yes
No

From 0 - 10 How Happy do you you think your future will be?

Selected Value: 0

Ho much do other people affect your Happiness or Sadness?

100%
80%
60%
40%
20%
Not at all

How long does this effect last?

Long term
Short term
It depends on who it is

Thanks, you're all done. If there's anything else you'd like to tell us you can put that here. Otherwise, click 'Submit' and head over to your Account / Member's page to take a look around

Thank you for filling in our Audit Dock.

You will now be re-directed to your My Account Page

We’re really looking forward to meeting you in your first coaching session 😊

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TERMS & CONDITIONS

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About
Join
Contact
Faq’s
Our Team
Members
PRIVACY POLICY & GDPR
TERMS & CONDITIONS

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