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Break Free Application
Breathe. Center in your body and heart. Are you excited? Nervous?
This application is confidential and a space to feel safe. Let's dive in and see if our souls connect!
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First and Last Name
Your answer
Email Address:
Your answer
Phone Number:
Your answer
Tell me a little about yourself. What do you like? Do you have any hobbies? Are you in a relationship? Do you have kids?
Your answer
What is your vocation? Do you like your work? Is it fulfilling?
Your answer
What keeps you up at night? Where are you feeling trapped in your life right now?
Your answer
On a scale from 1-10, how trapped do you feel?
1
2
3
4
5
6
7
8
9
10
Clear selection
What are you biggest struggles and hurdles? What are your biggest obstacles to overcome right now?
Your answer
Do you have an physical symptoms of your emotions? Tightness in your chest? Stomach aches? Headaches?
Your answer
Where do you feel unseen? In what way do you wish people (lovers, friends, parents, colleagues) would notice you more?
Your answer
Do you currently have someone safe to talk to? Someone you really trust who you can tell all your truth, pain and thoughts to?
Yes
No
Maybe
Clear selection
Who are you afraid of hurting if you live your dreams?
Your answer
Have you ever taken medication for mental illness (depression, anxiety, bipolar, PTSD, etc?)
Yes
No
Clear selection
Were you raised with a set of religious or spiritual beliefs? If so, please describe how they affected you.
Your answer
What are you biggest dreams (dream big here, anything is possible!)?
Your answer
If you were able to overcome your struggles, what would your life look like? Who would you be? (Give me ALL the details... get juicy. Tell me who you are with, what you are wearing, how you feel!)
Your answer
Why do you called to work with me? Why do you feel we would be a good match?
Your answer
Is there anything else that you want me to know?
Your answer
How willing are you to invest time, energy and financial means into this program?
Your answer
Do you have or are you willing to find the means you need to invest in this program?
Your answer
What do you hope to achieve by working together?
Your answer
Are you ready to commit to 2 months of working 1:1 to create a life where you feel FREE?
Your answer
Do you have any final thoughts, questions or anything else you want me to know?
Your answer
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