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BARRETT
COMBATIVES
Custom Self Protection Solutions
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QUESTIONNAIRE
SELF DEFENSE CLIENT QUESTIONNAIRE
Please complete this form to help me understand how I 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
Email
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
No
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
NO
If YES, please explain:
Submit
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