Intake Form

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Intake Form

Intake form

Email *

Name you like to go by *

I understand Kelly's sessions are unique and dive deep into the nuances of human nature to assist in reprogramming oneself from the inside out. These sessions are a call to my highest presence with myself, and require my dedication to implement what I learn so that I feel the full effects of my ability to change my life. *

I understand and am committed to my evolution

I'm still hoping someone will save me

List the painful and uncomfortable experiences from your life. These can be things ranging from: physical/emotional pain, bullying, depression, medical surgeries, accidents resulting in physical and/or emotional pain, abuse (sexual, physical, emotional, mental), homelessness, addiction (yours or loved ones), poverty, natural disasters, terrorism, death of a loved one, abandonment, mental states like depression, OCD, bipolar, foster care, etc. For ALL injuries/surguries/diseases, please list which side of the body it was on and what the medical term was for the disease.
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On a scale from 1-10, how committed are you to resolving these challenges?
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Eh, just checking this out

Full on ready to go deep!

What was your relationship like with your mom and dad growing up? How has it shifted now? *

List the current challenges you’re desiring to to work through and gain clarity on. *

What would your life be like if you were able to be free of these challenges and feel great?
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What are you currently doing and have previously done on behalf of your healing process?
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Send me a copy of my responses.

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