QUESTIONNAIRE

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BARRETT COMBATIVES

Custom Self-Defense Solutions

SELF DEFENSE CLIENT QUESTIONNAIRE

Please complete this questionnaire to help us understand how we may best help you reach your self-defense and personal safety goals.

First name*

Last name*

Birthday*

Month

Day

Year

Phone*

Email*

Preferred Contact Method*

Phone

Text

Training Goals

What are your main reasons for seeking self-defense training? Check all that apply.*

Improve personal safety awareness

Build confidence

Learn practical escape skills

Prepare for travel, work, school, or commuting

Recover confidence after a past incident

Fitness, coordination, or stress management

Other

Describe your top three self-defense goals for the next 30–90 days:*

Experience and Comfort Level

Have you taken self-defense, martial arts, boxing, fitness, or tactical training before?*

Yes

If YES, please describe

How would you describe your current confidence level?*

Low

Moderate

High

Unsure

How comfortable are you with physical contact during training?*

Not comfortable

Limited contact

Moderate contact

Comfortable with contact drills

Do you prefer private, partner, or small-group training?*

Private

Partner

Small group

Unsure

Safety Concerns and Daily Environment

Are there specific situations, places, or routines where you feel less safe?*

Walking alone

Parking lots

Public transportation

Workplace

School/campus

Home environment

Travel

Social settings

Other

Please describe any specific concerns you would like the instructor to understand before training begins:*

Health, Mobility and Training Considerations

Please share anything that may affect training safety, pacing, or technique selection: Current injuries, pain, or physical limitations: Medical conditions or medications relevant to physical activity: *

Learning Style and Boundaries

How do you learn best?

Demonstration

Step-by-step instruction

Repetition/drills

Scenario practice

Written notes

What training pace works best for you?

Slow and detailed

Moderate

Challenging

Unsure

Are there topics, scenarios, or drills you DO NOT want included?

YES

If YES, please explain:

Phone: 508.851.9390

Email: Inquiries@barrettcombatives.com

Liability Waiver

Client Questionnaire

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