Profile Form

Personal Assessment for Consultation

I invite you to join me on a journey to juice up your life! This work is deep and personal so I like to know you intimately, enough to best support your needs and help you achieve your greatest goals! Please only fill out what you are comfortable sharing. Speak with you soon!

Name*
First
Name
Last (optional)
Gender*
- Male
- Female
Birthdate*
MM
DD
YYYY
Best Email Address*
Best Phone Number
Occupation*
Are you interested in:
- Private Sessions
- Workshops
Are you in a relationship?
- Yes
- No
If yes, is your partner joining you? (If so, fill it out together or have them fill out a separate form)
Relationship dynamics. Challenges
Briefly describe your relationship (or past relationships) dynamics?
Desires and difficulties:*
What are you striving for? What challenges you struggle with?
On a scale of 1 - 10 how ready are you in resolving your issues?*
What is your desired outcome from our work together, in 3-6 months?*
Have you any background in personal awareness, spiritual practices like Tantra, Yoga? Martial Arts, dance, massage etc?
How did you find me?
What country, city, state and zip code do you live in?
Also include other locations where you'd like to meet.
Thank you for your time. Any Comments or Questions you'd like to Ask?
Email
This field is for validation purposes and should be left unchanged.

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Profile Form

Personal Assessment for Consultation