Call Enquiry Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone number (optional)For call reminders - no marketing
4
Are you a woman who is struggling with unhealthy relationship patterns and chronic self abandonment?* This field is required.
YESNO
5
What's your current relationship status?* This field is required.
Please Select
Please Select
Recently broken up
Single and dating
Single and NOT dating
In a relationship/marriage, but want to leave
In a relationship/marriage, and want to stay
6
Which of these best describe your goal on your healing journey? (check any/all that apply)* This field is required.
I want to break my cycle of unhealthy relationships and stop my self abandonment.
I want to learn how to clear the trauma causing my patterns not just from the mind, but from the body.
I want to learn self love, healthy boundaries and how to trust myself.
Ultimately I want to attract a healthy partner and have a beautiful, loving relationship.
Not sure - I haven’t thought about it yet.
7
How ready are you to break free of your romantic relationship patterns?* This field is required.
Right away!
In the next few weeks
Maybe in a few months after I think about it
8
Are you willing and able to invest in getting the guidance necessary to overcome these patterns?* This field is required.
Yes, this a priority and I have the financial means to invest in myself and prioritize my healing
Yes, I may or may not have all the funds but I am extremely resourceful and will find a way to make it happen
No, my cash flow is month to month and I have no access to any funds or credit to invest in myself
No, I’m not looking to invest and want to do this on my own
9
If we decide to work together, how driven are you to commit to your healing journey?* This field is required.
I'm 1000% dedicated to succeeding!
Honestly I've been dragging my feet on this - I'm finally ready to do this!
I'm not really sure - I want to talk to someone then see how I feel.
I don't really want to work with anyone.
Other
10
What specifically inspired you to schedule a call to learn more about joining my program? (Please describe in detail)* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
Have you invested in therapy, other coaching programs, counseling or other forms of professional help? Please also explain why were they unsuccessful.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
12
Please confirm that you 100% will attend the call you book with us and that you will be there prepared to make a YES/NO decision.
Yes I'll be there and I'll be ready to make a YES/NO Decision.
Yes I'll be there but I won't be ready to make a decision.
No I won't be there.
13
What country do you live in?* This field is required.
14
What is your timezone? (leave if unsure)
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