Crystal Clear Coaching Application
Are you ready to discover your POWER and PASSION so you can feel empowered, enriched, and purposeful?

So we can make the best use of our time together in this BREAKTHROUGH COACHING and HEALING SESSION, please fill out the form below. This way, I get to know more about you and then we can spend the entire time on your TRANSFORMATION.
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Email *
Name *
Phone *
How did you find me? *
Describe your current situation. What brings you to me? *
How long have you been experiencing this current situation? *
What do you most want to change today? *
If you have you tried to change this before, what have you attempted that didn't work? Why? *
On a scale of 1-10, how important is it for you to achieve change today? *
Least important
Most important
On a scale of 1-10, 1 being the lowest, how committed are you to accomplishing your needs and reaching your goal?
lowest level of commitment
highest level of commitment
Clear selection
Do you currently: *
Is there anything else? Please let me know if you have any pressing questions or concerns.
Thank you
Once I receive this information, we'll be ready for your first appointment - a Crystal Clear Coaching Session ($100 Wellness Coupon applied). Based on our conversation, you'll receive a follow-up message with further options and/or instructions.
Thank you so much for for taking the time to answer this brief survey. I look forward to speaking with you.

Rosemary Levesque
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