Information Request Form

Thank you for your courage and interest in doing THE WORK

Please take a big breath before you fill in this form in the most honest and authentic way possible. Your openness allows me to determine how I can best support you and make the best out of our time together - With love, Ana
Name
example@example.com
E-mail
Phone Number

Area CodePhone Number
Which service are you interested in?(you can select several)

Psychospiritual MentorshipSomatic SessionPrep for CeremonyPost - Ceremony IntegrationRecovery Mentorship (Addiction/Meds)
Please share why you are interested in this kind of service and what you'd like to get out of it
What are the biggest challenges you are facing in life right now? (If we already had a conversation on this, you can skip it)
How does your current life differ? What do you feel you need to let go of in order to create this?
What vision do you have for yourself, what kind of life and business would you like to create or develop further? (If we already had a conversation on this, you can skip it)
Select however many describe you

I am open to new ideas and to trying things out even if they are outside of my comfort zoneI want change but I am too busy to work on my goals and building my dream lifeI am receptive to feedbackI know that in order to get better, I need support and accountabilityI know that in order to develop my business and life vision, I need to investI have a hard time listening to others who are trying to helpI talk a lot and have a hard time stopping or listeningI am able to sit with discomfort without the need to escape or numbOther
Tell me some things you find unique about yourself, as well as some strengths
What are some ways in which people have showed up around you in times of need, that you have found most supportive?
If you currently receive other kinds of support (mentorship, coaching, therapy), please share what kind, for how long, and how you feel it has benefited you
What would make our sessions worthwhile for you? How would like to measure progress?
Please share any social profiles or businesses/projects you lead, your birth date and anything else you find important for me to know
Thank you for your time, vulnerability and authenticity.
Should be Empty:

Thank you for your courage and interest in doing THE WORK

Thank you for your time, vulnerability and authenticity.