Discovery Call Intake Form

Today's Date*

YearMonth Day
Date
Name:*

First Name Last Name
Email:*
example@example.com
Phone Number*

Area Code Phone Number
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Date of Birth:*

MonthDay Year
mm-dd-year
How did you find me?*

GoogleFacebookYouTubePodcast
If you could choose one of the following outcomes, which would be the most meaningful to you? (Choose as many as apply.)*

1. Get free from being stuck or blocked2. A deeper spiritual connection3. More satisfaction in my career4. Improved relationships with family, friends and co-workers5. Greater control over my thoughts6. Enhanced ability to manage my emotional states7. More creative influence over my external world8. Attract my soulmate9. Get free from vows, curses, spells and/or agreements
Of those you checked off above, which 3 are the most important to you?*
Please indicate using the item #
What do you believe are the biggest obstacles to having the outcomes you identified above?*
The more details you give me, the more I will be able to assist you.
Please list all modalities that you have explored to remedy these problems. (ie: therapies, healing work, spiritual practices, alternative therapies, certifications, etc.)*
If there are a lot, please just list your favs.
Are you presently taking anti-depressants, anti-anxiety medication or any other form of medication that affects your state of mind?*
Do you meditate?*

YesOccasionallyNo
Have you ever had profound experiences, visions and/or dreams that left you knowing that there is so more to life than what you are presently experiencing?*

Yes, onceYes, more than onceNo
Right now,*

I have the financial resources to invest in myself.I have access to the financial resources to invest in myself.I don't have any financial resources and am quite happy keeping my life where it is.
Is there anything you would like to add?
Once you hit submit, you will be re-directed to the booking portion of this initial intake application. Please select the preferred time for your Discovery Call.
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