Pre Enrollment Application
Must complete questionnaire for program consideration. Please allow 48 - 72 hours for response.
Email address
First/Last Name
Your answer
Telephone Number
Your answer
Are you in crisis? If "yes", answer next 2 questions. If not SKIP next 2 questions.
Your answer
Are you in physical danger? If so, call 911.
What is the nature of your crisis?
What is the situation that led you to contact me?
Your answer
How long have you been dealing with it?
What is your anxiety level around the issue?
Do you have a hope for how this turns out or an "ideal resolution" you're hoping for...what is it?
Your answer
Have you tried other things/therapy/coaching to resolve this issue? If so, what? What were the results?
Your answer
Are you willing to have your beliefs challenged to help bring about the mindset transformations needed for a healthy, positive outcome?
What else do you want me to know about your situation before we speak?
Your answer
I understand that the call is being recorded and that it is confidential.
The following is true, I...
Where did you hear about me?
Your answer
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