Awake & Recover Joy: 10-Week Program Application
Tell me about you and let's see if this transformational journey can truly help you - I want to help you find the best fit. I value everything you share and hold all information purely confidential.
Name
First Name
Last Name
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship Status - explain if needed :)
Parenting Status - kids at home/ages?
Occupation - if a homemaker, how do you spend your days?
What specifically is going on for you right now that has you filling this out… what’s not working?
What would you like in your life? If you had a magic wand that would uplevel you to the kind of person you wanted to be, what would that person be like?
What's kept you from becoming that person so far?
Have you invested in yourself for therapy or coaching or personal retreats etc. before?
What do you feel like you need from a therapist/coach to make that happen?
What would be the benefits to you, your health, your relationships, your family, or anything else if you were to become the sort of person you want to be?
What time frame are you looking for help in - is this immediate, in the next month, next 6 months, next year? Just curious on your time frame.
Is there anything else you'd like to let me know before we chat?
Thank you for sharing!
I'll send you a link for a video chat very soon.
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