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I would like to offer you a complimentary 30-minute conversation with no obligations! We will work together to develop an effective healing strategy that will help you recognize your emotional blocks and how to overcome your challenges so you can achieve your goals with confidence.

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First name

Last name

Code

Phone

What main emotional health challenge would you like to overcome? Why is it important to you?

What do you feel are your biggest obstacles preventing you from reaching good emotional health?

What is motivating you to invest into improving your emotional health?

What other emotional healing modalities have you done in the past?

Psychotherapy

Psychiatrist

Life coaching

Divorce coaching

None

Other

If you have tried any of these healing modalities, what would you like to do differently this time? and why?

Do you suffer from any of the following?

Depression

Anxiety

Self-sabotage ie. suicidal thoughts

None

Programs may recommend making lifestyle changes throughout the healing process, including self-care, journaling, meditation, regular exercise and/or setting healthy emotional boundaries. Are you willing to make lifestyle changes in order to improve your emotional health?

Yes

Do you have any additional comments or concerns?

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