Full Name *

Name

Email *

Phone *

State or Province *

1. Briefly describe your current relationship with your adult child. *

2. What do you believe has been the biggest challenge in your relationship with your adult child? *

3. What have you already tried to improve the relationship? *

4. Which statement best describes where you are today? *

I'm hoping my adult child will make changes that improve our relationship

I know we both have a part to play, and I'm open to understanding mine.

I believe lasting change begins with how I choose to show up, even if my adult child doesn't change right away.

5. Reconnection Reset Circle focuses on your own growth, emotional steadiness, communication and relationship skills. What appeals to you about that approach? *

6. This program is designed to support you over six months. While I encourage you to attend as many live sessions as possible, I understand that vacations, seasonal holidays, illness, family, work, and business commitments are part of life. The important thing is your commitment to your own growth—not perfect attendance. On a scale of 1–5, how committed are you to showing up consistently for yourself and the group? *

This is a priority; I'll show up fully.

Very committed; I'll make this work.

Fairly committed, though life gets busy.

Somewhat committed; not sure yet.

Still thinking it through.

7. How would you describe your readiness to learn, reflect, and try new ways of approaching your relationship? *

I'm fully ready — I know real change takes courage and I'm committed

I'm mostly ready, but a little nervous

I'm curious, but I'm not sure I'm ready for this level of personal growth yet.

I'm still figuring out if this is for me

8. Have you ever participated in a group coaching or group therapy setting before? *

Yes, and I loved the group experience

Yes, but I generally prefer 1-on-1

No, but I'm open and excited to try it

No, and I have some hesitation about it

9. What draws you to a group format for this kind of work? e.g. community support, shared experiences, accountability, cost… *

10. Looking ahead six months, what would you most like to be different about yourself? *

11. Is there anything else you'd like me to know about you or your situation before I review your request? Share anything that feels important

Thank you for taking the time to complete this survey.

If Reconnection Reset Circle feels like the right fit, I'll send you an invitation ASAP to enroll along with the next steps.

If I don't believe Reconnection Reset Circle is the best fit for your current needs, I'll let you know honestly and respectfully.

I look forward to connecting with you

Warmly,

Wendy