Welcome to the Self Study

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This form collects baseline data for each participant in The Self-Study. We are excited you are committed to this 30 day journey. We collect this information to help you meet your goals and stay on track!

Email *

Record my email address with my response

I'm taking The Self-Study because (check all that apply)
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I'm sick of my own repetitive cycles

I have unhealthy eating or lifestyle behaviors

I am reactive emotionally and it creates drama in my life

I struggle with relationships and communication

I'm worried I am parenting in a way that will repeat how I'm living my life

I know there is something missing and I need to figure out why I feel lost or empty

I'm always open to self-discovery but life is great - no complaints

I experience anxiety or depression and it's debilitating

Other:

Required

The experience I want throughout the 30 days is:
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Filled with community & accountability

A solo journey where I can be with myself and have 1:1 guidance mostly

Open to a combination

Whatever gets best results

I've tried to following to address my issues in the past
*

Therapy / Counseling

EMDR

Life Coach

Self-Help Books

Going it alone

Pretending I don't have an issue

Other:

Required

I currently experience ( check all that apply) *

depression

anxiety

anger / rage issues

frustration / feeling of powerlessness

addiction issues

relationship issues (lack of belief alignment, intimate issues, communication issues or other )

PTSD or CPTSD

Phobias

OCD or fixation

Parenting struggles

Insomnia or nightmares

Disordered eating (binging, purging, restricting, etc )

Other:

Required

Do you have children?
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No kids

How would you currently rate your communication style and efficacy?
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Chaotic, disruptive and tense

Reciprocal, respectful and symbiotic

How would you currently rate your ability to respond to adversity without getting reactive or taking things personally?
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Extremely challenging

Not an issue for me

How would you currently rate your ability to understand what drives your behavior, decision-making and choices beneath the surface?
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No idea what's going on up there - doesn't make sense to me

I understand why I behave this way and it is not a problem for me

Success in this work would be (check all that apply)
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Productive communication

Tools that restore peace and collaboration

An understanding of what is happening behind the scenes that makes me repeat chaotic cycles

Changed behavior / stopping self-sabotage

Decreased or non-existent anxiety or fear

Clear strategy to put into place at the end to know how to stop the cycle

Other:

Required

My biggest self-sabotage mechanism is?
*

My goal for the end of 30 days is
*

What is your best contact email?
*

What is your best phone #?
*

Name *

Send me a copy of my responses.

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