The Sacred Yes
Victorious Living Foundation
Confidential & Secure
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Step 1 of 4

Welcome to Your Intake

Before your first Sacred Yes session, each partner completes this assessment individually and confidentially. Please answer honestly — there are no right or wrong answers. Your responses help Dr. Cotton provide the most appropriate support and care.

🔒 All responses are strictly confidential and are used solely by the VLF clinical team. This assessment is never shared between partners, nor with any third party, without your written consent.

I am completing this as…

Your clinician will use this to follow up. It will not be shared with your partner.

Step 2 of 4 · Section A

Conflict & Communication

For each question, select the response that best applies to you. Where prompted, provide a brief written explanation.

🔒 Your responses are confidential and seen only by your clinician.
1. When you and your partner argue, what typically happens?
2. Do you ever feel unsafe at home?
3. Are you ever uncomfortable with the way conflict is handled between adults in your home?
4. Does anyone in your immediate family have concerns about the way anger is handled?
Step 3 of 4 · Section B & C

Personal Safety & Partner Behaviour

These questions are sensitive. Please answer as honestly as you can. Your responses are strictly confidential and help ensure your safety and wellbeing.

🛡️ If any of these questions raise concerns about your immediate safety, please contact emergency services or reach VLF directly at +1-721-524-8731.
Section B — Personal Safety & Fear
5. Have you ever felt afraid of your partner?
6. Do you feel safe with your partner?
7. Do you feel safe in your home?
8. Have you ever been physically hurt by your partner, or felt threatened by them?
9. Have you ever been — or are you currently — concerned about harming your partner?
⚠️ We want to make sure you are safe.
One or more of your responses has indicated a potential concern for your safety or wellbeing. Our clinician will review your responses and will reach out to you privately before your joint session. You are not alone — we are here to help. If you are in immediate danger, please call emergency services.
Section C — Partner Behaviour

Please answer each item separately and honestly.

C1. Has your partner ever pushed, grabbed, slapped, choked, or kicked you?
C2. Has your partner ever forced you to have sex, or made you do sexual things you did not want to do?
C3. Has your partner ever threatened to hurt you, your children, or someone close to you?
C4. Has your partner ever stalked, followed, or monitored you without your consent?
Step 4 of 4 · Final Step

Anything Else & Your Consent

This is your space to share anything additional that would help us support you well — and to give your consent before submitting.

Consent & Acknowledgement

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Thank You — Your Intake Is Received.

Your Relationship Wellness & Safety Inventory has been submitted securely and confidentially to Dr. Nicole E. Francis Cotton and the VLF team.

  • 1Your clinician will review your responses within 1–2 business days.
  • 2You will receive a private confirmation email at the address you provided.
  • 3If any response requires individual attention before your joint session, your clinician will reach out to you directly.
  • 4Your partner should also complete their own individual intake — please share this link with them privately.
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"You said Yes to each other. Now you are saying Yes to the preparation. That is courage."
Dr. Nicole E. Francis Cotton