I invite you to answer a few essential questions!

Application for The Heart Formula® Program

Please complete this questionnaire as thoroughly as possible before our consultation. It will give me a clear picture of your situation and help me determine whether I can genuinely assist you. I personally review every response and all information you share will remain strictly confidential.

If I see that I can help you, my assistant will contact you within 48 working hours to arrange your session. Consultations take place via video call on the Zoom platform. Please note that all scheduled times are set according to the GMT+1 time zone.

If I believe that I am not the right fit for your needs, I will let you know as I do not want to waste your time or money on a process that would not bring you results.

Your answers will also allow me to gather essential background information in advance, so we do not spend valuable consultation time on basic questions. This way, we can use every minute of our time together as productively as possible. The more I know about you, the better I can prepare and make the session truly worth your investment.

Your email address:

Your first and last name:

Your phone number:

Your date of birth (you must be over 21 years old):

How long have you been in your current relationship?

Less than one year.

One to three years.

Three to seven years.

More than seven years.

Do you currently live with your partner?

Yes, we live together.

No, but we plan to live together.

No, and we have no such plans.

We live separately due to relationship problems.

What's your relationship status?

We are dating.

We are planning engagement.

We are engaged.

We are married.

We are in separation.

Do you have children together or from previous relationships? (You can choose few answers).

Yes, we have children together.

I have children from a previous relationship living with me.

I have children from a previous relationship living separately.

My partner has children from a previous relationship living with him.

My partner has children from a previous relationship living separately.

We do not have children.

I am currently pregnant.

Describe everything you believe I should know about you, your relationship and your goals before the session:

How would you describe the current state of your relationship?

Stable, but emotionally distant.

Stable and positive.

Uncertain and unstable.

On the verge of breaking up.

In the past 12 months, has anything happened that seriously affected your relationship?

No.

Yes, but the situation has been worked through.

Yes, and the issue still has a real impact on the relationship.

Has there been infidelity in your relationship? (You can choose few answers).

No.

I'm not sure, but I think my partner did cheat on me.

Yes, my partner cheated, but the issue has been resolved.

Yes, my partner cheated and it still affects the relationship.

Yes, I cheated, but the issue has been resolved.

Yes, I cheated and it still affects the relationship.

Has physical violence ever occurred in your relationship?

Never.

Once.

Several times.

Yes, it happens regularly.

What typically happens after an argument in your relationship?

We stop speaking to each other.

One of us disappears for a few days.

We verbally attack each other.

We talk in order to resolve the problem.

We pretend nothing happened.

Does your partner respect you in front of friends and family?

Yes.

Usually.

Rarely.

Never.

Does your partner know that you are applying for this program?

Yes, and he supports this decision.

Yes, but he is indifferent.

Yes, but he is skeptical.

No, he does not know.

How does your partner approach working on the relationship?

He is engaged and wants change.

He declares willingness but takes little action.

He tends to avoid the topic.

He openly refuses to cooperate.

Would your partner be willing to change his behavior if necessary?

Yes, genuinely.

Maybe.

Probably not.

Definitely not.

How does your partner usually react to conversations about relationship problems?

He speaks calmly and rationally.

He listens but does not take action.

He becomes defensive or attacks.

He shuts down or escalates the conflict.

Do you expect resistance from your partner during the program?

Not at all.

Minimal.

Significant.

Very strong.

If the process requires changes in your life, would you accept that?

Yes.

Probably yes.

Reluctantly.

No.

How much time are you able to dedicate to personal work between sessions?

Less than one hour per week.

One to three hours per week.

Three to five hours per week.

In the coming months, do you have any planned events that could disrupt the program, such as a move, surgery, or long trip?

No.

Yes, minor events.

Yes, major events.

I am not sure yet.

Do you have the conditions for calm and private work during sessions?

Yes.

Usually yes.

Rarely.

No.

Which program track are you currently considering?

Regular Track, fifteen sessions.

Fast Track, five intensive sessions.

I would like you to advise me.

Are you considering ending the relationship regardless of this program?

No.

I have doubts.

I think about it often.

Yes.

What is your main reason for applying to this program?

I want to save the relationship.

I want to improve the quality of the relationship.

I want to build the relationship consciously.

I want to separate and focus mainly on my personal development.

How do you react when the process becomes emotionally uncomfortable?

I stay and continue working.

I feel resistance but keep going.

I start questioning the purpose.

I withdraw.

Have you previously started relationship work and not completed it?

No.

Once.

Several times.

Many times.

Do you accept that not every relationship can or should be repaired and that, if this applies to you, the program may focus mainly on your personal growth?

Yes.

Probably yes.

I am not sure.

No.

Do you accept that change will begin primarily with you?

Yes.

Probably yes.

I am not sure.

No.

How soon would you like to start the program after acceptance?

As soon as possible.

Within one month.

Later.

What are your preferred contact hours (GMT+1)?

10:00 a.m. – 2:00 p.m.

2:00 p.m. – 6:00 p.m.

* I declare that I have read the Terms and Conditions and the Privacy Policy, and I accept them in full.

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Application for The Heart Formula® Program

Your email address:

Your first and last name:

Your phone number:

Your date of birth (you must be over 21 years old):

How long have you been in your current relationship?

Do you currently live with your partner?

What's your relationship status?

Do you have children together or from previous relationships? (You can choose few answers).

Describe everything you believe I should know about you, your relationship and your goals before the session:

How would you describe the current state of your relationship?

In the past 12 months, has anything happened that seriously affected your relationship?

Has there been infidelity in your relationship? (You can choose few answers).

Has physical violence ever occurred in your relationship?

What typically happens after an argument in your relationship?

Does your partner respect you in front of friends and family?

What are the main problems in your relationship? (You can choose few answers).

Does your partner know that you are applying for this program?

How does your partner approach working on the relationship?

Would your partner be willing to change his behavior if necessary?

How does your partner usually react to conversations about relationship problems?

Do you expect resistance from your partner during the program?

If the process requires changes in your life, would you accept that?

How much time are you able to dedicate to personal work between sessions?

In the coming months, do you have any planned events that could disrupt the program, such as a move, surgery, or long trip?

Do you have the conditions for calm and private work during sessions?

Which program track are you currently considering?

Are you considering ending the relationship regardless of this program?

What is your main reason for applying to this program?

How do you react when the process becomes emotionally uncomfortable?

Have you previously started relationship work and not completed it?

Do you accept that not every relationship can or should be repaired and that, if this applies to you, the program may focus mainly on your personal growth?

Do you accept that change will begin primarily with you?

How soon would you like to start the program after acceptance?

What are your preferred contact hours (GMT+1)?

Please correct the following:

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