Empowerment Jumpstart Form

Welcome! Let’s get a sense of where you’re starting from and what you'd love to get out of the Empowered Self Defense classes. There are no right or wrong answers—just answer honestly. This will help us tailor the experience to your needs at and support you in the areas that matter most.

.🔎 1️⃣ Choose Your Home Location. Pick the location where you’ll primarily attend:

White Plains (Tuesdays)

Nyack (Thursdays)

Sloatsburg (saturdays)

🔥 2️⃣ Where You’re At Now

For each of the following, choose the statement that best reflects you:

A. Boundaries & Assertiveness

I often agree to things I don’t really want to do.

I sometimes struggle to say no, especially with people I care about.

I’m usually able to set boundaries but sometimes feel guilty or second-guess myself.

I am comfortable and confident setting clear boundaries.

B. Safety & Awareness

I rarely think about personal safety in daily life, but if I do it's with anxiety and fear.

I sometimes feel uncertain about how to handle unsafe or uncomfortable situations.

I feel fairly confident but want to sharpen my instincts and skills.

I’m highly aware and proactive about my personal safety.

C. Presence & Confidence

I often feel anxious or distracted.

I try to stay present but sometimes find it hard to stay grounded.

I usually feel calm and present in most situations.

I feel powerful, clear-headed, and calm in almost most settings.

D. Technology & Distraction

I’m often glued to my phone or feel distracted by technology.

I’m aware of my technology use and trying to manage it.

I’m fairly balanced with my phone and tech use.

I am very intentional about minimizing distractions and staying present.

E. Self-Trust & Decision-Making

I often doubt my instincts or decisions.

I’m working on trusting myself more but still second-guess at times.

I generally trust my gut and stand by my choices.

I have strong self-trust and rarely question my decisions.

F. Putting Myself First

I often put others’ needs before my own, even to my own detriment.

I’m working on prioritizing myself but still struggle.

I’ve gotten better at putting myself first when it matters.

I'm not perfect but I consciously prioritize my own needs and wellbeing.

📝 4️⃣ Anything else you'd like me to know? (Feel free to share anything else, and it's always confidential.)

First name

Last name

Email

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