The Playful Path Portal Survey

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number* This field is required.

Please enter a valid phone number.

7

Describe any current pain (how long has it been, where is it located & what intensity 1-10)* This field is required.

9

if other, please explain

10

What do you feeling upon waking for the day....* This field is required.

dread

excitement

curiosity

frustration

12

Describe your stress in life?* This field is required.work, personal, financial, pressure

13

How would you like to feel on a daily basis? * This field is required.

14

Are you willing to take Self Responsibility for how you feel?* This field is required.

YESNO

16

Are you currently working with a therapist or life coach?* This field is required.

YESNO

17

Are you mindfully choosing your own thoughts?* This field is required.

YESNO

18

Are you willing to explore sitting still with your discomfort? * This field is required.AKA step out of your comfort zone?

YESNO

19

Do you have a GRATITUDE practice?* This field is required.

YESNO

20

Are you willing to invest financially for your healing and well being?* This field is required.

Not at this time

YES i'm ready

Maybe, if its a right fit

21

What addictions (if any) do you use to cope?alcohol, drugs, food, social media

22

Book a Free 30 min Discovery call here* This field is required.Choose an ideal time and day for me to reach out to you.