Phone Number *
What is Your Occupation? *
How did you hear about me? *
Friend or ColleagueSocial Media (Facebook, Twitter, YouTube, etc)Referral From Another ProfessionalOther
Do you have children? *
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? *
Describe the results you experienced? *
Please rate your distress TODAY due to your issue? * (1 is feel good, not a problem – and 10 is worst ever)
Please rate your distress GENERALLY due to your issue?* (1 is feel good, not a problem – and 10 is worst ever)
What 3 things will be different/better in your life if this problem was gone? *
What would you love to change as a result of working with me?
How has the issue of unworthiness shown up in your personal or professional relationship history? Or do you have any other areas of focus, I may help you with? *
In your opinion, in this moment, what commitments and changes are you willing to take to have more fulfilling relationships, intimate Connection and sexual aliveness?
How would you know you were successful?
Do you have any financial, emotional, situational barriers that might interfere with partaking in the Soulful Relating Programs? *
Without being humble, what is it that you value most about yourself and what strengths would you like to build on?
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