EmailMe Form - Single You Academy Survey

Date *

MM / DD / YYYY

Name *

Age *

What do you (race) identify as? *

Do you identify as one of the following? *

Female

Male

Transgender

Non-binary

Now let's talk about your past relationship(s) and/or current relationship. *

I'm single

I'm in a relationship

I'm married

Would you say you're good at setting boundaries in your relationship(s)? (past or present) *

No

Yes

Not really

Would you say your current relationship and/or past relationships have been: *

So happy and fulfilling

Just ok

Heavy and physically hurtful

A burden on me emotionally and more

Would you say in your relationship(s) (past or present) you: *

In this statement "relationships are hard" -- do you clearly understand the difference between healthy hard vs. dysfunctional? *

Yes

No

Not really

Would you attend a program/meeting/event that discussed how to have healthy relationships? *

Yes

No

Absolutely because no one has ever had a conversation with me about what makes a healthy relationship vs. an unhealthy relationship.

If you attended this program / meeting / event what would you want to learn about relationships? *

How to set and keep boundaries

What is Self love

How to have a better relationship with myself

How to have a healthy romantic relationship

All of the above

Do you think a program centered around personal healing, self-worth, and relationships is needed in this community? *

Yes, especially in the BIPOC community

Yes, especially for emotional, spiritual, sexual, and physical healing

Yes, especially for proactive services in promoting healthy relationships

All of the above

What do you need guidance and support in the most right now? *

Understanding who I am, my worth and being able to execute that with my actions

Setting boundaries

Understanding the difference between healthy vs unhealthy (relationships)

All of the above

What would prevent you from attending a program / meeting / event that discussed how to have a healthy relationship? *

Would you like to be informed when Single You Academy host a program / meeting / event that discusses how to have a healthy relationship? *

Yes Please!

No

If you said yes please leave the best way to get a hold of you example; phone number or the best email you have.

Anything else you want to share with us about you and/or your past or current relationships?

Email *