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You're in the right place. This short form helps me get a sense of where you'd like support so we can make the most of our time together. Your answers are fully confidential.

CONTACT INFO


Name
Phone
E-mail
Preferred Contact Method:
E-mail    Text    Phone Call

WHAT WOULD YOU LIKE SUPPORT WITH?


(Select all that apply)

Weight Loss
Anxiety / Stress
Confidence / Visibility
Nervous System / Emotional Regulation
Energy Work / Reiki
Business or Life Coaching
Sleep or Fatigue
Smoking / Vaping Cessation
Other (briefly describe):

IF YOU COULD FEEL DIFFERENT TOMORROW, WHAT WOULD BE DIFFERENT?

(1-2 sentences)

HAVE YOU EVER EXPERIENCED:

(Select any that apply — optional)

Hypnosis    Coaching    Reiki or Energy Work    None of the above   

IS THERE ANYTHING ELSE YOU’D LIKE ME TO KNOW BEFORE WE MEET?

(optional open box)

I understand that services provided are complementary and not a substitute for medical or psychological care.
I agree