Name
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First Name
Last Name
Email
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Phone
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Country
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Date of Birth
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MM
DD
YYYY
Exact Hour of Birth
if you know it
Hour
Minute
Second
AM
PM
Place of Birth
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What services are you interested in?
What keeps you awake at night, or if you wake up in the middle of the night, what occupies your mind?
What would be your ideal outcome after our sessions? List five clear goals you want to work on during the mentorship session/s.
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Do you have any regular practices?
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How does an ideal day look like for you?
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What are the challenges to live it? What holds you back?
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Are you currently receiving medical care and/or on any medications? (please specify conditions being treated and medications taken.) Include physical, mental and emotional health.
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Have you had any major surgery in your life, and how recently?
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How is your diet? What food habits and food cravings are you experiencing at the moment?
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How did you enter the world? What do you know about the gestation period and your birth?
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please include what you know: type of birth, where where you born, labour details, duration, any complications, interventions, breastfeeding, was the father present, how was your mother feeling, how were you as a baby?
Do you feel safe in your body and during intimacy? Which responses or emotions usually occur?
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How is your intimacy? Please check the ones that are true for you
Are you currently working on something specific? Are you currently in any type of counselling?
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What are the preferred hours to work together where you could be in your own space and without the potential of being interrupted?
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Would you like to mention anything else which may be relevant?
How did you hear about me?
social media
through a friend
live event