Confidential Luxury Therapy Access Request

Confidential Luxury Therapy Access Request

With Tierra Burns, LCSW
Name

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
1. What is the biggest goal or transformation you're seeking support with right now?*
2. What has shifted in your life that made you reach out at this moment in your journey?*
3. What are the emotional, mental, or professional consequences if this doesn't get addressed?*
4. What would it feel like to finally experience the desired breakthrough? (Use 3-5 feeling words?*
Are you currently experiencing burnout, leadership/performance anxiety, stress/pressure, or emotional exhastion?*
On a scale of 1-10, how committed are you to investing emotionally, mentally, and financially in your transformation?*

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
What does emotional wealth mean to you and how do you know when you're out of alignment?*
How do you lead in your current role? (CEO, athlete, founder/entrepreneur, lawyer, doctor, public figure, etc.) Describe the weight of the leadership?*
What have you already tried in the past (therapy, coaching, retreats, etc.) and why do you think it didn't fully work?*
Is there anything else you'd like to share about what you're looking for in a luxury-level emotional wealth partnership?*
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