Complimentary Rapid Breakthrough Session Intake Form Client Intake Questionnaire Thank you for your interest in a Free 1-hour Rich, Rewarding Life Session. Please complete the form below and submit it. A follow up email will be sent so you can schedule your free session! Name*TitleFirstLast Email* Email confirmation* What do you feel is your biggest struggle right now?*My beliefsMy relationships with friendsMy romantic relationshipsMy feelingsMy jobMy incomeMy workplaceMy healthMy relationships with my childrenMy relationships with my parentsMy relationships with my siblingsMy behaviorMy weightTrust IssuesFaith in MyselfConfidenceSelf-respectSelf-loveSelf-careGiving too much to othersOther What have you tried in the past to help solve this struggle?*NothingTherapyCounselingComunicationVisualizingDietsExerciseTalking to FriendsSelf-Help BooksOnline classesOnline GroupsPrayerChurch groupDoctor VisitPrescriptionsEverythingHypnosisCutting CordsOther What 3 feelings would you like more of in your life right now?*LoveJoyHappinessPeaceEmpathyExcitementResilienceConfidenceFaithValuedFulfillmentRespectCherishedConnectedCarefreeSecureSelf-RespectSelf-LoveEnergeticEnthusiasticOther On a scale of 1 to 5, with 1 being not at all and 5 being completely, how committed are you?*1 - Not at all, I think change is too hard or too scary to try2 - Barely, I'm not ready to take any real actions3 - Somewhat, but I need a lot of constant, instant gratification4 - Very committed, but some things are just not possible5 - Completely willing to do whatever it takes Enter characters for verification. I consent collecting this data and processing it according to {{privacy-policy}} of this website.SubmitReset
