Questionnaire for Speeches or Poems

The purpose of this questionnaire is to enable Rabbi Cohen to gain a thorough insight into the character, personality, achievements and interests of the subject of this speech or poem, so that it can be made as personal and relevant as possible.

All information will be treated in the strictest of confidence, and will be destroyed immediately after the composition has been dispatched to you.

Please fill out all entries in this section:

Your Full Name:
Your spouse / partner's name: (if applicable)
Phone number:
email address:
Relationship to subject of composition:

I would like Rabbi Cohen to compose a speech/poem/dvar Torah for the following occasion:

Special Birthday: (please specify)
Wedding Anniversary:

For a Bar or Bat Mitzvah:

Name of the Bar or Bat Mitzvah:
Hebrew name:

Date and place of religious event and of celebration:

For a Bar Mitzvah How much of the Sidrah/Haftarah you are reading:

Whether you found the learning of your portions easy or difficult:

Names of Rabbi & Chazan:

Name of BM tutor:

For a Bat Mitzvah The nature of your preparation: (recognised course or private learning) and under whose auspices:

What form the religious event will take:

Where the religious event will take place:

The venue for the celebration:

Any novel theme being introduced at the party:

What is the theme of your Dvar Torah: (if applicable)

Schools attended to date:

Any special academic, musical, vocal, sporting or dramatic talent: (please describe in full)

Any distinctions attained in these areas or notable performances:

Any special hobbies or leisure persuits:

Any grades or exams for which the B.M is still practising or in training:

Any special ambitions:

An academic high flyer or average student:

Appearance and any notable physical characteristics:

Overly/very/quite particular about appearance: (add any relevant details)


Lots of/few/friends:
Sense of humour: (please describe)

Intelligence: High or average IQ / special needs:

An avid/average reader for pleasure: (please list the books especially interested in)

/regular/infrequent user of the computer: (please specify average daily use and purpose - e.g: gaming, football manager, notice board or chat line to friends, etc)

Preference for Holidays:

In-school clubs or societies attending:

Out-of-school clubs or groups: (please detail name(s) and average time per week spent at each place, degree of interest, etc.)

Any near scrapes, scary events, memorable or eminently forgettable occurrences:

Which Cheder attended: (if applicable)
Degree of religious commitment:
Attainment in religious studies:

Names of any special friends: (in order of closeness)

History of relationship, reminiscences, etc:

Nature of relationship with parents:

Names of siblings: (in order of age)

Nature of relationship: (specify the areas where, if older, they are specially helpful; if younger how BM relates to them)

Full names of grandparents and (if blessed) great grandparents:

Any special aspects of the relationship with the older generation:

Any relatives or special friends attending from abroad: (please provide details)
Any special thanks or appreciation to be highighted:

Please add any information not categorised above, references that should be either avoided or emphasised, or any impending life-style changes occasioned by divorce or re-marriage of parent, house move, emigration, etc.), regarding which you might wish Rabbi Cohen to be especially tactful: