Phone Number *
What is Your Occupation? *
How did you hear about me? *
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What is the main reason you want to talk with me in regards to your relationships, communication, desire or sexuality? *
Give a brief account of the history and development of this issue (onset to present): *
What else have you already tried to address this issue? *
What would you love to change as a result of working with me?
Is there anything else you wish to share that you feel is important for me to know?
Thank you for taking time to complete this form. I will be in touch right away to schedule your complimentary Self Discovery Call.
In Love, Service and Appreciation