SHARE YOUR EXPERIENCE WITH FINANCIAL DEPENDENCY

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Thank you so much for your interest in sharing your experience with Financial Dependency.  Please answer the survey questions below.  Note: your information will be kept confidential. 

This Form cannot be submitted until the missing fields (labelled below in red) have been filled in
1. I've experienced being Financially Dependent on a spouse/partner
Me Someone I know
2. I've experienced being Financially Dependent on a job or career
Me Someone I know
3. I've experienced being Financially Dependent on family or friends
Me Someone I know
4. I've experienced being Financially Dependent in a relationship where there has been physical or emotional abuse
Me Someone I know
6. I've experienced being Financially Dependent in the following other situations:
6. My experience with Financially Dependency was
By Choice By Circumstance
7. My experience of being financially dependent was because of:
My financial situation (debt, overspending, lack of a plan) Lack of skills and resources (never learned how to manage my money) Lack of interest in managing the money Relying on someone else to manage the money Job loss Illness or addiction Emergency or tragedy I don’t know why Other - explain below
8. What’s the biggest challenge that you are facing right now with your money/finances?
9. The following topics are being covered in my upcoming book - which are you interested in?
Financial literacy Why Financial Dependency occurs How Financial Dependency happens How to recover from or prevent Financial Dependency Resources and support Other topics you are interested in - list below
10. I would like to share my financial dependency story, please contact me
Yes No
First Name
Last Name
E-Mail Address
Phone
11. If your story/information is approved and included in the book are you willing to sign a release form?
Yes No
12. I am interested in getting exclusive access and updates to your upcoming book launch
Yes No
Enter contact info if not entered above: Name
Email:
12. Please enter any questions and/or comments you have:
Please enter the word that you see below.