Personalized Vision Form

Personalized Vision Form

This is more than a form—it’s your starting point.The questions below are designed to help me understand your current challenges, your emotional goals, and the kind of support that speaks to your life. Everything you share will be used to create a personalized, non-clinical action plan—crafted with care, intention, and your unique journey in mind. You don’t need to have all the answers—just be honest. This is your space to begin rebuilding peace, clarity, and momentum, one step at a time.
Section 1: General Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you give consent to use this information strictly for the creation of your Personalized Action Plan™ (not therapy)?*

YesNo
Who else is important in your life right now (children, spouse, pets)? Include names, if comfortable. (Example: My daughter Ava (age 6), my partner Jordan, and our dog Max)**
Section 2: Understanding the Situation
Which emotional or mental health challenges are you dealing with right now? (Check all that apply)*

AnxietyDepressionRelationship or marital IssuesTrauma or PTSDGrief and lossStress or burnoutAngerMood swingsLoneliness or isolationLow motivationNegative self talkAttention or concentrationOther
Describe what's been hardest for you lately? (Use your own words and be as detailed as you would like.)*
What's one emotion (or more) you wish you could feel more of right now (e.g., peace, control, energy, clarity)?*
What has this challenge impacted most in your life?(Check all that apply)*

WorkSchoolRelationshipsParenting or caregivingFaith or spiritualityMotivation/energySelf-worth or identityPhysical healthAttention and focusedSensory issues
What triggers your biggest emotional responses or patterns you notice? (This helps tailor intervention strategies more effectively).
Section 3: Goals and Growth
What coping strategies have you found helpful in the past or still using (Check all that apply)

Journaling and writingExercise and working out (e.g, taking a walk, gym, yoga)Deep breathing and grounding exercisesPrayer and meditiationListening to musicVideo gamesCookingCreative arts (e.g, drawing, painting, crocheting)Driving or riding in a carSpending time with family and friendsTravelingOther
Describe for me your typical "day in the life."
What are some feelings and emotions you want to feel more of in the next 3–4 months? (e.g, gratitude, patience, confidence, more disciplined)*
As life becomes a little more manageable soon, what would that look like for you?*
What are 2 or 3 small goals you'd love to work toward right now (emotional, lifestyle, or mental)?*
What habits or thought patterns would you like to improve or break?
Describe your strengths, positive traits, and areas you do well in.
Section 4: Design & Personal Touches
Upload a cover photo (optional): (family photo, pet, nature, quote background, etc.)

Cancelof
Preferred tone for your plan’s language:

Gentle/EncouragingBold/AssertiveMotivationalReflective/InsightfulTeaching/LectureDoes Not MatterOther
Do you want any of the following included in your plan? (Check all that apply)

AffirmationsMetaphors and AnalogiesGuided Journaling PromptsMood and Daily TrackersChecklist or Habit BuildersVisualization ExercisesQuotesNone
Other: Write in you preferences in the plan
Write out any personal inclusions: (e.g., personal affirmations, spiritual references, mottos, journaling prompts
Section 5: Practical Wellness Needs
Where do you need the most support right now? (Check all that apply)*

Daily structure and routineEmotional regulation and groundingBuilding confidenceReconnecting spirituallySetting boundariesParallel parentingImproving sleepManaging stress and fatigueTurning pain into purpose after lossRebuilding after traumaFinding motivation
Do you want more:

Structure and routineFlexibility and adaptabilityEncouragementStrategy and direct toolsAll the above
Section 6: Add-Ons and Bonus Options
Would you like a personalized Power Script™ added? (Motivational writing that speaks directly to your situation)

Yes (+30)No
Would you like a 30-minute consultation to go over your plan in depth?

Yes (+100)Not right now
How would you prefer to use your PAP?

Print it out and write it in (e.g., binder)Use digitally on my phone/laptopUse as a PDF journal + planner combination
What else should The Counselor's Corner know about your story or your needs so I can serve you well?
Other remarks and requests you would like in your plan, or for The Counselor's Corner to know?

My Products

Personalized Action Plan™

No sessions. No fluff. Just a therapist-built roadmap made for your life.

$249.99 Quantity

Reset Year™

A full-year emotional transformation, without the burnout of traditional therapy.

$4,997.99 Quantity

30/30 Vision Meeting

The 30/30 Vision Meeting is a one-time, 30-minute strategy session designed to help you gain clarity, make confident decisions, and walk away with a personalized action step — fast. Whether you're feeling emotionally stuck, mentally overwhelmed, or just unsure of your next move, this meeting gives you therapist-level insight without entering therapy.

$100.00 Quantity

Customized Power Script™

Sometimes, you don’t need more advice — you need a message that speaks directly to your experience, lifts the fog, and pushes you forward. That’s exactly what a Customized Power Script™ delivers.

$30.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

✅ Your plan will be thoughtfully crafted and delivered within 3-5 business days. You’ll receive a confirmation email upon submission. For the 30/30 meetings, you will receive email confirmation for scheduling.
🔒 Please note: Due to the personalized and digital nature of this service, all sales are final. No refunds will be issued once your submission is received.
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Personalized Vision Form

Section 1: General Information

Section 2: Understanding the Situation

Section 3: Goals and Growth

Section 4: Design & Personal Touches

Section 5: Practical Wellness Needs

Section 6: Add-Ons and Bonus Options

✅ Your plan will be thoughtfully crafted and delivered within 3-5 business days. You’ll receive a confirmation email upon submission. For the 30/30 meetings, you will receive email confirmation for scheduling.