Name *

First Name

Last Name

How would you rate your life right now? Lowest - Highest

1

2

3

4

5

What motivated you to reach out?

I'm am fed up with not making change & feel like I am ready to take the steps

My actions are impacting my relationships

I'm feeling stuck

I want to learn to manage my stress better

I'm in a habit that I feel that I can't change on my own

Other

How long have you been feeling like this?

A few weeks

The past 6 months

Over a year

For as long as I can remember

What has stopped you from taking action before?

Fear

Money

Timing

I needed longer to know that I wanted to make change

Other

What experiences resonate with you?

Pick as many as you need to.

Anxiety - Stress & Worry

Performance Anxiety / Fear of failure

Social Anxiety

Relationship Stress

Work / Life Stress

Emotional Eating

Struggle with Motivation

I struggle communicating my needs and feelings

Procrastination

Life Direction & Implementing Change

People Pleasing

Body Image / Self Esteem

I struggle to slow down

Other

What would you like to achieve?

What areas would you like to focus on the most?

Self Confidence & Self Acceptance

Better relationship with food & my body

Trust & Confidence within my relationships

To be able to sit with myself & my feelings

Communication

Less pressure & expectation

To change an unhelpful habit or behaviour

Manage my stress better

To deal with negative thoughts & feelings better

Other

If you don't change your current behaviour or how you are presently feeling, what will be the impact of this?

I'll continue to feel stuck

I'll remain exactly where I am & I don't want to continue experiencing what I am

My relationships, health, work & mindset will be impacted

I'll experience the same behaviours

I won't be happy

Other

Are you currently on medication?

Yes

No

How ready are you to make change?

I know I have to make change

Kind of

Good to go, but I need the tools

Very Ready