LAC Action Plan Call Form

Please Fill Out The Form Below

Your Call Booking Is NOT YET CONFIRMED, we need a few more details from you first to ensure that we help you get the best out of your call. Pease complete the form below to confirm your booking.
Name*

First NameLast Name
Email*
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Mobile Number*
Age*
Are you currently:*

WorkingEmployedBusiness/Self-employedStudyingUnemployedRetired
How did you hear about us?*

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Do you have any major life changes coming up e.g. moving home, travelling, another course, that would stop you from fixing this problem right now?*
What's the worst thing about this problem and how is it affecting your life?*
What do you want to achieve from working with me, what's the BIG goal/outcome?*
Do you have the financial resources to invest in a high-level, transformational programme IF what I have is EXACTLY what you need to finally heal from betrayal, feel calm and confident again, and stop letting his choices control your life?*

Yes I have money to invest in finding a solutionYes I can access money to invest in finding a solutionNo I cannot invest in myself right now

Where are you on this scale of 1–10? (1 being “I’m not very serious about healing from this betrayal,” to 10 being “I’ll do WHATEVER it takes to feel free, calm, and in control again.”*

	1	2	3	4	5	6	7	8	9	10

1 is , 10 is

Anything else you feel I should know?
I give permission for you to email me*

Yes
We run the call on Zoom video so that we can see each other and connect properly. Please confirm that you can get a free Zoom account ready for the call. We understand that not everyone knows how to access or use Zoom so if you need help with this please tick 'No' below and email us at info@fresh-forward.co.uk*

YesNo
This best describes me (please tick just one):*

I am someone who would invest in myself to solve a problem and make needed changesI am someone who feels resistance to this but would do it anyway if it was right for meI am someone who would never invest in myself, dislikes change and would rather stay as I am
Are you currently working with anyone else on this issue (please give details)?*
Do you suffer from epilepsy?*

YesNo
Do you suffer from a psychotic illness?*

YesNo
Are you currently in a situation where you feel unsafe or believe your life may be in danger? (This is asked only to protect your wellbeing — not to assess eligibility.)If you answer “Yes,” please know my programme isn’t suitable at this stage, and it’s vital that you contact an emergency or crisis support service for immediate help instead.*

YesNo
Please confirm that you will show up to the Zoom call or cancel if you can't make it as we have a waiting list and the appointment can be given to someone else in need*

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