Application
Are you truly ready to transform your life and commit to lasting change? If you’re serious about creating the life you desire—one filled with balance, health, and fulfillment—this is your opportunity.The application below is designed to ensure that we’re a good fit for working together. I work with clients who are committed and ready to take action. If you’re ready to step into your power and make real changes, fill out the application, and let’s begin your journey toward positive change! I will be in touch within 24-48 hours after receiving your application to discuss the next steps.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
When is your birthday?
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-
Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your occupation?
Type a label
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How did you hear about me?
Type a label
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Marital Status
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Married
Single
Divorced
Widow
It's complicated
Do you have any children? If so, how many?
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Have you been hypnotized before?
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Yes
No
What would you like to achieve? Check all that apply
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Get healthy
Reduce anxiety
Reduce stress
Ease depression
Ease PTSD
Stop worrying
Increase self-confidence
Improve focus/concentration
Practice mindfullness/meditation
Emotional management
Is there anything else you would like help with?
List your top 3 issues from above, in order of importance.
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How do you believe your life will be better once you make these changes? Personally, professionally, spiritually?
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Are you prepared to invest in your positive transformation?
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Yes
No
What other methods have you tried to resolve these problems?
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On a scale of 1-10, how coachable are you?
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1 - Resistant to feedback
2
3
4
5 - Somewhat open to feedback
6
7
8
9
10 - Fully open to feedback, ready to take action!
What brings you joy? What are your hobbies/activities?
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Do you follow any religious or spiritual practices? If so, please describe briefly.
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Which of the following vacation destinations do you enjoy? (Select all that apply)
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Beach
Mountains
Cities
Foreign countries
All the above
Please use the area below to add any further thoughts or information you think may be helpful or relevant in any way.
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