Full Name

What issue(s) you are seeking help with

• Fear or Phobia
• Anxiety or Stress
• Trauma or Emotional Block
• Allergies or Asthma
• Chronic Pain
• Medical Fear
• Sleep Issues
• Confidence or Self-Esteem
• School/Learning Challenges
• Relationship or Family Stress
• Habit Change
• Performance or Motivation
• Other
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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? *

BadGood

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?

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