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
Do you give consent to use this information strictly for the creation of your Personalized Action Plan™ (not therapy)?
Who else is important in your life right now (children, spouse, pets)? Include first names, if given consent. (Examples: My daughter Ava, my partner Jordan, and our dog Max)*
Section 2: Understanding the Situation
Choose Your Areas of Focus (Check all that apply)

Other
What are primary situations that tend to make things harder for you, or what patterns have you noticed?
What's one emotion (or more) you wish you could feel more of right now (e.g., peace, control, energy, clarity)?
Choose Impacted Areas of Life (Check all that apply)
Section 3: Goals and Growth
What are coping strategies have you found helpful in the past or still using (Check all that apply)

Other
Describe for me your typical "day in the life."
What improvements do you want to make 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.)

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Preferred tone for your plan’s language:

Other
Do you want any of the following included in your plan? (Check all that apply)
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
Choose Areas of Growth (Check all that apply)
Do you want more:
Section 6: Add-Ons and Bonus Options
Would you like a personalized Power Script™ added? (Metaphorical story that outlines and speaks directly to your situation)
How would you prefer to use your PAP?
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. A personalized educational wellness roadmap built around your goals, preferences, and priorities.

$249.99 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

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✅ Your plan will be thoughtfully crafted and delivered within 5-7 business days. You’ll receive a confirmation email upon submission. Check your inbox frequently for your plan.
🔒 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

My Products

✅ Your plan will be thoughtfully crafted and delivered within 5-7 business days. You’ll receive a confirmation email upon submission. Check your inbox frequently for your plan.