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Name (First and Last)*

Age*

Email address*

Phone Number*

City of Residence*

I want to have friends but don't know how to meet people.

Yes

No

I feel nervous about going to new places.

Yes

No

Other people don't seem to understand me.

Yes

No

I can do more with my life than I am doing now.

Yes

No

I would like to manage my home life better.

Yes

No

I would like to find a new job or change jobs.

Yes

No

I would like to find a place where I feel like I can belong.

Yes

No

I have been told that I am not motivated.

Yes

No

I worry about the future.

Yes

No

I am ready to take one step towards changing my future.

Yes

No

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