First Name

Last Name

Magical Name/ Or Alias

Select your Gender

Birth Year

Best Way to reach you?

Phone Number

Email Address

Getting To know you:

1) WHAT ARE 3 to 5 Outcomes that you would like to get out of receiving coaching in this journey over time?

2) What are 1 or 2 outcomes you would like out of one session?

3) What do you perceive is in the way (3 to 5 things) of you

having the delicious relationship and/or life you long for?

4) On a scale of 1 to 10 (10 being severe or even once extremely. 1 being rarely or never). . . How much Emotional Abuse did you experience in your family or childhood?

(Shaming, blaming, guilting, denigrating, yelling, criticizing, neglect, lack of touch or nurturing behavior

5) On a scale of 1 to 10 (10 being severe or even once extremely. 1 being rarely or never). . .

How much Physical Abuse did you experience in your family or childhood? (Hitting, striking, slapping, the belt, the paddle, the brush, the whip, the branch, being thrown, being restrained, being left or neglected , being physically threatened etc.?)

6) On a scale of 1 to 10 (10 being severe or even once extremely. 1 being rarely or never). . .  How much Sexual Abuse did you experience in your family or childhood or adulthood? (Being forced, coerced, manipulated or shamed into giving or receiving sexual touch, conversations, things to watch, and/or intercourse etc.)

7) On a scale of 1 to 10 (10 being severe or even once extremely. 1 being rarely or never). . .How much Spiritual Abuse did you experience in your family or childhood? (Being forced, coerced, manipulated or shamed into believing or adhering to beliefs that were not authentic for your spirit and/or felt wrong to you.)

Do you have any questions, comments, concerns or memories that you must elaborate on? If so, feel free to write as much or as little as you are comfortable with.