Confidential Luxury Therapy Access Request
With Tierra Burns, LCSW
Name
First Name
Last 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?
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3. What are the emotional, mental, or professional consequences if this doesn't get addressed?
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4. What would it feel like to finally experience the desired breakthrough? (Use 3-5 feeling words?
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Are you currently experiencing burnout, leadership/performance anxiety, stress/pressure, or emotional exhastion?
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On a scale of 1-10, how committed are you to investing emotionally, mentally, and financially in your transformation?
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Worst
1
2
3
4
5
6
7
8
9
Best
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?
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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?
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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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