Name

First Name

Last Name

What do you love about your life right now? *

What’s not so great about your life right now? *

If money and life situation were no barrier, what would you be doing right now? *

What have you always wanted to do but never done? Why? *

What's your greatest challenge right now? * Think about your family, children, relationships, career, inner fulfilment + joy?

What’s missing from your life right now? * Is there anything that calls to you? Something that you long for?

How would you describe your current state of health and wellbeing? * Think broadly about your level of satisfaction with your physical body and energy, mental health and wellbeing and emotional health.

At what time in your life did you feel your best? List three reasons why you felt so good at this time. *

Do you experience feelings of stress, overwhelm or anxiety? *

Yes - a few times a month or less

Yes - more than once a week

Yes - several times a week or daily

Can you identify any of the triggers? * Write anything you know to trigger feelings of anxiety, overwhelm or stress or simply write, I don't know or N/A

What is one thing you value or love about supporting the person you care for?

What is the biggest challenge you face as a carer or parent to someone requiring additional care?

What is one goal you have for yourself right now? *

Is there anything else you want to tell me? *

Have you ever tried EFT, meditation, breathwork or other healing modalities before? *

Yes

If yes, please list or explain what you've done and your experience