1:1 Student Application
Thank you for your interest in my 1:1 private coaching.

Private Coaching is secured for those seeking more 1:1 support, are ready to take a deep dive into their healing and co-create a safe container to support a unique healing process.

I just want to say "thank you". It takes courage to reach out for guidance and share details of your healing journey. Just know, I appreciate the steps taken to show up here.

Below you'll find a series of questions that will help me better understand you and your nervous system.

I honor your needs to safe keep parts of your story, therefore if you find that some questions might be helpful to share at a later time or better shared in conversation, please feel free to make a note of that instead.

Thank you for taking the time to bring me into your journey. I look forward to supporting you.
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First and Last Name:
Best Contact Email Address:
Age:
Time Zone:
Please share 1-3 words or phrases that you value:
Please describe your current goals (details are encouraged, so please don't be shy): *
Please tell me a bit about your health journey (what did you learn, what are your struggles?)
How long have you been searching for way to understand your symptoms + your body?
Clear selection
Please describe any injuries you have experienced (please include as much detail as you feel comfortable - ex. which side of your body, what year, what happened, did you go to physical therapy, are you currently still experiencing pain, symptoms or discomfort?):
Please describe any surgeries that you may have had (this also includes cosmetic surgeries, botox).
Do you have any tattoos? If so, when did you get them and where are they located?
Have you had any dental work (braces, cavities, fillings, root canals etc)? Please describe below.
Are you on any medications or take any supplements? If you feel comfortable, please share them below:
Do you wear contacts or prescriptions? If you happen to know your prescription, please share that below?
What is 1-3 areas you are looking for support & guidance?
Why is now the time to take action in achieving your health goals & investing in coaching?
How will you know that you've achieved your desired outcome by the end of our coaching?
What about working with me interests you the most?
Are you ready to place yourself in the driver's seat of your healing journey or do you need more time to decide if this is for you?
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Is there anything that is on your mind that you would like to share with me? Please feel free to "brain dump" below:
I offer payment plans and extended payment options to best support this work for students—with that said, how do you feel about investing in a program right now? *
How did you learn about my services?
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Thank you for allowing me into your journey. xx, Alyssa
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