Eligibility Questionnaire – ComXtra Knowledge Concepts

ComXtra Knowledge Concepts – DEW Counselling

Psychoeducation Group Sessions For Married Muslims

28th January – 18th February 2022

Please note that each person must answer and submit separately

Name *

First

Last

Gender *

Female
Male

Email *

Confirm Email

Phone *

Name of Spouse *

First

Last

Email of Spouse *

1. How long have you been married? *

enter value in years

2. On a scale of 1-10, with 1 as Unsatisfactory to 10 as Very Satisfactory, how would you rate your relationship?

3. Why do you want to participate in this programme?

4. What do you and your spouse succeed in doing, in your communication?

5. What do you and or spouse struggle with, in your communication?

6. What are some of your qualities you consider to be strengths?

7. What are some of your qualities you consider to be your weaknesses?

8. Do you and or your spouse have any health issues of concern?

9. Do you and or your spouse have any history or currently experiencing any mental illness/mental health condition?

eg, Depression/Anxiety etc

10. Have you had or currently have difficulty controlling your anger?

11. Have you ever experienced, currently experiencing violence in your relationship?

12. Can you commit an investment fee of $500 for the 4 Sessions?

Payable fully before start of programme
Part payment to be completed before end of programmed

13. Can you commit an investment of time to attend – 3hrs per session for 4 sessions of this programme?

14. Are you fully vaccinated?

Please note that this is a condition of entry into the venue for the programme.

15. Do you have any dietary requirements?

16. Do you need childcare to be provided for an additional fee?

17. Do you have any questions or comments?

ComXtra Knowledge Concepts is a Counselling, Coaching, Creativity Consult that seeks to empathize, enable, enhance, energize, empower and elevate, communication in and for individuals, in human relationships and systems, in extraordinary ways by learning, in living and through life.

Summayyah Sadiq-Ojibara

Counsellor and Psychotherapist

CEO/MD ComXtra-DEW

Email: summayyahsadiq@comxtra.com

Email:help@comxtra.com

Website: www.comxtra.com

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