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Name______________________________________Date______________________Address ___________________________Telephone Numbers___________E-mail Address: _________________Please fill in the circle that most closely matches your reaction to the question and mail to Sat Tara Kaur Khalsa, MS, LPC, P.O. Box 20874, Boulder, CO 803081. I seek the company of other people frequently.2. I am able to trust a member of the opposite sex.3. I feel reasonably ready to go on a date.4. I maintain my sense of self in a relationship.5. I feel ready to work on a long-term relationship.6. I can relate to my ex in a reasonable manner.7. I can usually reveal secrets easily to the right person.8. I am a loner.9. My parents had a healthy relationship.10. I feel ready to be sexual in a relationship with someone I trust.11. I have some fears about being with someone sexually.12. I have many close friends.13. I handle criticism well.14. I have had a healthy sexual relationship in the past.15. I am usually comfortable when anger or disagreements first arise in a relationship.16. I can go 24 hours without a thought about my past relationship.17. I am comfortable with my body.18. I have abused substances for a period of time in the past 5 years.19. I am comfortable if I realize someone is attracted to me.20. I experienced physical or sexual abuse as a child.21. I experienced a good level of intimacy in my last relationship.22. My parents were easy to open up to.23. When I meet a person, they usually like me.24. I know my own relationship patterns.25. I think I could be ready for an exclusive relationship six months from now.RELATIONSHIP READINESS REVIEWI am currently offering a 3-session personal package I call RELATIONSHIP READINESS REVIEW to help you better asses your readiness to have a healthy, fulfilling long-term relationship.Areas of focus include:The ability to deal with fear, rejection, shyness, and isolationAssessing if a potential partner is a good candidate for intimacyLearning how to stop working against yourself in intimate relationshipsWhat to look for in a partner so they suit your individual strengths and weaknessesGaining confidence in dating, choosing a partner and in relationshipsFocused work on the specific areas that hold you back from having a healthy, happy, healing relationshipThis process can be educational, empowering, and deeply healing. You can give me a call at 303-530-7080. I look forward to hearing from you!