Name

First Name

Last Name

Why do you want support in this container?

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

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

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

List any goals you are working towards at the moment. If you don't current have any, create five goals and share them with me *

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

Are you interested in learning about the healing modalities I offer (EFT, breathwork and coaching)?