The Embodied Reset Application

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Name
First Name
Last Name
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Email
example@example.com
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Phone Number
Area Code
Phone Number
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Instagram Handle
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Location and Time Zone
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What made you click on this application today?What are you feeling, experiencing, or going through right now that’s calling you to seek support?
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Ok
Ok
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In your own words, what’s not working in your life right now?Feel free to talk about energy, mindset, emotions, health, relationships—anything you want to shift.
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Ok
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What have you already tried to “fix” or change this?Programs, therapy, habits, routines, etc.
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Ok
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If we were to work together and your life looked exactly how you wanted it to in 6–12 months, what would that look and feel like?Don’t hold back—paint the picture, in detail.
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Ok
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What would change in your life if you felt calm, confident, and fully in control of your energy and emotions?Be honest. This is your chance to name your desires.
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Ok
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Why do you feel now is the right time to receive support at this level?Why not keep doing what you’ve been doing?
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This is a deep, high-touch coaching experience. Are you open and ready to explore your patterns, shift your energy, and do the work?
Yes, I’m ready
I’m nervous, but I’m open
Not sure yet
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This is a deep, high-touch coaching experience. Are you open and ready to explore your patterns, shift your energy, and do the work?
I’m ready to invest now
I need to explore financial options, but I know I want this
I’m not sure if I’m ready to invest at this level
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Is there anything else you want to share with me before I review your application?Open space for honesty, fears, or excitement.
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Ok
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If we’re a good fit, are you open to receiving next steps via email or Instagram DMs?
YESNO
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