Name

Phone

Email

Skype (Optional)

Describe the area of life you would like help with

What do you most want to do/feel/create?

What is stopping you?

What have you tried before?

What support do you currently have?

What does success with this issue look like to you?

I work in a unique way, combining energy healing skills and coaching techniques and applying principles from the ancient practice of meditation. Have you had experience with energy healing or meditation? I work in a unique way, combining energy healing skills and coaching techniques and applying principles from the ancient practice of meditation. Have you had experience with energy healing or meditation? Yes, I have lots of experience Slightly, I have dabbled a bit No, I have no prior experience

Making changes in your life can be challenging at times. The intention of this question is to provide clarity when setting intentions and expectations around our work together. Have you been medically diagnosed with a physical or psychological illness? Making changes in your life can be challenging at times. The intention of this question is to provide clarity when setting intentions and expectations around our work together. Have you been medically diagnosed with a physical or psychological illness? Yes No

Are you currently under the care of a licensed health care practitioner for this? Are you currently under the care of a licensed health care practitioner for this? Yes No

How did you find me/who referred you?

In compliance with new privacy laws, the following checkbox is required: In compliance with new privacy laws, the following checkbox is required: I consent to the privacy policies on this website (found in footer)

Number

Name

Email:

Phone

Skype (Optional)

Please describe the area of your life you would like help with

What do you most want to do/feel/create?

What is stopping you?

What have you tried before?

What support do you currently have?

What does success with this issue look like to you?

I work in a unique way, combining energy healing skills and coaching techniques and applying principles from the ancient practice of meditation. Have you had experience with energy healing or meditation? I work in a unique way, combining energy healing skills and coaching techniques and applying principles from the ancient practice of meditation. Have you had experience with energy healing or meditation? Yes, I have lots of experience Slightly, I have dabbled a bit No, I have no prior experience

Making changes in your life can be challenging at times. The intention of this question is to provide clarity when setting intentions and expectations around our work together. Have you been medically diagnosed with a physical or psychological illness? Making changes in your life can be challenging at times. The intention of this question is to provide clarity when setting intentions and expectations around our work together. Have you been medically diagnosed with a physical or psychological illness? Yes No

Are you currently under the care of a licensed health care practitioner for this? Are you currently under the care of a licensed health care practitioner for this? Yes No

How did you find me/who referred you?

In compliance with new privacy laws, the following field is required: In compliance with new privacy laws, the following field is required: I accept the privacy policies of this website (found in footer).

Number