Form: Custom Program pre-assessment

Custom pre-assessment

Your Mailing Address with Zip Code*
Your birth name and date of birth (Ex: 1/1/2011)*
The name you are currently going by (first and last please!)*
Who are 3 people or brands you admire in your life and why?*
(Although this may seem unrelated, it is helpful in getting clear on what you value which will definitely guide our work!) Ex: I LOVE Kate Winslet for her authenticity in every role she plays and I feel like I can trust her/she’s “real.”
Give me an overview of where you’re at in your life, specifically the 1 or 2 areas you want to work on*
(Ex: Health and Relationships). Tell me what’s working and not working. Tell me what you love and what frustrates you. I promise to never judge you!
What are your top 3 challenges right now in your life? If you’re just getting started, what do you perceive as the top 3 areas where you feel lost, confused or unsure?*
If you manifested a “breakthrough” during our time together what would that look or feel like? Describe below in detail.*
What do you want help with most right now?*
Past Relationships and Family Influences: Is there a pattern in your approach to the area you want to look at that you are already aware of? Describe it for me as best as you can (we’ll be diving way deeper together).*
Ex: In love: I always attract the emotionally unavailable players or I always attract men who cheat on me. Or In approaching clients, I feel scared to say what I charge so I just let them decide or I barter with people to avoid dealing with money.
Growing up, what did you learn about love/relationships from your parents? How was love demonstrated/not demonstrated in the home? Be as specific as you can as we may be diving into lineage blocks and patterns!*
Is there anything else you’d like to share with me before we begin our journey together?
Email address*