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Full Name
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First Name
Last Name
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2
Email Address
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example@example.com
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3
Instagram Handle / Facebook Page / Personal or Business Website
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Instagram.com/yourname
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Phone Number
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5
Where are you in the world/What time zone are you in?
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6
Have you experienced a somatic approach to therapy or coaching before?
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Somatic Therapy
Coaching
Both
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7
What about my work prompted you to reach out? Was there a specific post, a theme, a feeling, an insight?
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8
What feels alive, tender, challenging, or ready to shift?
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9
If we did end up working 1:1 together and things unfolded beautifully… what would you hope would feel different for you in 6 -12 months?
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10
On a scale of 1-5, how ready do you feel to actively participate in your own growth right now?
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1 (not ready)
2
3
4
5 (100% ready)
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11
Women’s Embodiment Psychotherapy Coaching is a truly holistic modality that works with all layers of your being. It’s about Reweaving Wholeness which is to know the rightness of being both soft and fierce as a woman — it’s about trusting the magic of letting your body lead you in your life. What is your financial capacity and willingness to invest in this deep & transformative on-going 1:1 support over a 6-12 month period?
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$0 - $500
$500 - $1500
$1500 - $3000
$3000+
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12
Preferred method of contact
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Email
Text Message/Voicenotes
Private Message on Instagram or Facebook
I’d be keen for a face to face chat if possible (Zoom)
Other
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13
Thank you for taking the time to share yourself with me here. Based on your answers I will be in touch shortly with options for how I can support you. Is there anything else you’d like me to know?
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