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Relationshift Coaching Intake Questionnaire
Creating a Safe and Supportive Space
Introduction

Welcome, and thank you for taking the time to complete this form.


Our coaching community is built on respect, compassion, and safety. Every
woman’s story matters. This form helps us understand your needs and ensure that your coaching experience is supportive, appropriate, and aligned with your
well-being.


Some of the questions below are personal and may touch on sensitive topics such as stress, conflict, or emotional and physical safety. Please answer as honestly as you can. Your responses are strictly confidential and will only be reviewed by our coaching team for the purpose of ensuring your safety and receiving the right kind of support.


If you answer “yes” to any safety-related questions, one of our trained coaches may reach out privately to check in with you and make sure your coaching plan is adjusted with care and discretion.


You deserve to feel safe, respected, and valued. 💛

Section 1: Basic Information
Marital Status
Section 2: Coaching Readiness
2. When you feel triggered, how easy is it for you to pause, breathe, and stay curious instead of reacting?
3. When you receive feedback or a new perspective that challenges your current way of thinking, how do you usually feel?
4. Are you open to using spiritual language — such as Divine design, purpose, or Hashem’s guidance — as part of your coaching process?
5. How supported do you feel right now — emotionally, spiritually, or socially — outside of this program?
8. If you begin to feel triggered, uncomfortable, or unsure during the group sessions, are you willing to reach out for private support with a coach?
9. Do you believe that change is possible for you — emotionally, spiritually, or in your relationships?
10. How would you describe your current emotional state overall?
11. Have you ever been diagnosed with or treated for depression, anxiety, or another mental health condition?
12. Are you currently seeing a therapist, counselor, or coach?
13. Are you currently taking any medication for anxiety, depression, or emotional regulation?
Section 3: Emotional and Relational Well-Being

Four main emotional abuse domains:

 

  1. Fear / Intimidation – yelling, threats

  2. Humiliation / Ridicule – mocking, sarcasm, belittling

  3. Control / Punishment – silent treatment, financial control, withdrawal

  4. Distortion / Gaslighting – confusion, self-doubt, denial

Questions:

2. Do you ever feel afraid of your husband or of his reactions?
3. Have you ever felt like you had to “walk on eggshells” to avoid upsetting him?
4. Does your husband ever raise his voice, yell, or scream at you?
5. Has he ever called you names, cursed at you, insulted you, or put you down?
6. Does your husband ever ridicule or mock you, your thoughts, or your way of doing things?
6a. If yes, please check all that apply:
7. Does your husband ever twist your words, deny what happened, or make you doubt your own memory or reality? (Gaslighting)
7a. If yes, please check all that apply:
8. Has your husband ever hit, shoved, or physically hurt you in any way?
8b. How severe was it?
9. Has he ever hit, yelled at, or been physically rough with your children?
9a. How severe was it?
10. When your husband is upset, how does he typically react? (check all that apply)

11. Does your husband ever:

11a. Expect meals, chores, or intimacy on a strict schedule and get angry if it’s not met?
11b. Criticize or “correct” how you dress, speak, or behave?
11c. Monitor your phone, messages, or where you go?
11d. Limit your friendships, family contact, or time outside the home?
11e. Take or control your money or access to funds?
11f. Threaten to “teach you a lesson” or punish you for something he perceives as disrespectful?
11g. Lock you out of the house, car, or bedroom?
11h. Break or damage your belongings?
11i. Use Torah, religion, or “respect” as justification for control or punishment?
12. Have you ever felt pressured or forced into intimacy against your will?
13. Does your husband use anger or withdrawal as a form of punishment or control?
14. Can you express your thoughts or needs freely without fear of how he will respond?
15. Have you ever felt confused about whether what’s happening is normal or acceptable in marriage?
16. Has anyone ever suggested that your relationship may not be emotionally or physically healthy?
Section 4: Emotional Support and Next Steps
Confidentiality Statement

The information you share is reviewed only by our coaching coordination team. If your responses suggest that you may be in an unsafe or high-risk situation, we will reach out with sensitivity and care to help ensure you have appropriate support.


You are never alone. Support and safety come first.

Consent and Safety Acknowledgment

I understand that Relationshift coaching is educational and spiritual in nature, and is not a replacement for therapy, counseling, or professional mental health treatment.


I recognize that group coaching is a shared learning environment, and that advice or perspectives offered to one participant may not always apply to my individual situation. Each woman’s relationship dynamic and emotional history is unique.


If my situation involves any of the patterns or concerns described in the questions above, such as fear, ridicule, control, withdrawal, or physical or emotional harm, I understand that the guidance given in general relationship coaching may not be appropriate for me without adjustment.


In such cases, or if I ever feel unsure, uncomfortable, or dissatisfied with my progress, I am encouraged to schedule a private session with a certified Relationshift coach to ensure my safety, clarity, and individualized support.


Relationshift is committed to creating a community of compassion, honesty, and responsibility. I take ownership for my personal well-being and agree to seek additional guidance when needed.

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