Full Name
What issue(s) you are seeking help with
In your own words, what is the problem you want help with? When does it happen, and how does it affect your daily life?
On a scale of 1–10, how much does this impact your daily life?
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Bad
Good
What prompted you to seek help now?
What is your desired outcome from us working together?
What have you already tried before to fix this? What worked or didn't work?
What is this issue emotionally, physically, or monetarily costing you at the moment?