Transformation Preparation & Intake

1
NameWhat is your full name?
First Name
Last Name
2
EmailWhat email should session information be sent to?
example@example.com
3
Phone Number(optional but helpful)
Area Code
Phone Number
4
What time zone are you in?
5
City/Country
6
Have we worked together before?If yes, answer next question.
YESNO
7
When was your last session?
8
What brings you to this session?Share as much context as you feel comfortable with.
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Ok
9
Which area of life does this most relate to?
Self-worth/confidence
Relationships
Money/abundance
Career/purpose
Emotional healing
identity shift or life transition
Stress or physical symptoms
Other
10
How long have you been experiencing this challenge?What patterns or reactions do you notice?
Please Select
Please Select
Less than 6 months
1-3 years
Many years
Most of my life
11
When this issue shows up, what usually happens?What patterns or reactions do you notice?
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Ok
12
What have you already tried in order to resolve this?
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13
What emotions tend to show up around this issue?
Fear
Anxiety
Anger
Sadness
Shame
Overwhelm
Frustration
Confusion
Other
14
Do any of these patterns show up for you?
Overthinking
Self-sabotage
Procrastination
Difficulty setting boundaries
Feeling stuck despite trying
Physical tension or stress sympton
Other
15
What do you believe might be the deeper cause of the issue?
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Ok
16
Imagine the change you’re seeking has already happened — as if a wave of your wand cleared away everything that was never yours to carry. What would your life look and feel like afterward?Describe it as vividly as you can. How would you feel in your body? What would be different in your daily life, your relationships, and the way you move through the world? How would you think or behave differently?
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17
On a scale of 1-10 how ready are you to change this pattern or situation?1=curious 10=fully committed
18
What makes you that number instead of a lower one?
19
Which statement best describes your mindset toward this work?
I want someone to fix the problem for me.
I want guidance so I can create real change.
20
Are you currently working with a therapist, counselor, or similar professional?
YESNO
21
Are you currently taking medication for mental health conditions?
Yes
No
Prefer not to say.
22
Is there anything important about your story that you feel would be helpful for me to know before our session?
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Ok
23
Consent* This field is required.I understand that these sessions are for personal development and transformation and are not a substitute for medical or psychological treatment.
24
Signature
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